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Session: ePoster: Rectal Cancer 2 (Sun1230)

EP463 - Treatment Patterns and Outcomes for Locally Advanced Rectal Cancer 2015-2020: Total Neoadjuvant Therapy vs Standard Chemoradiation

Sunday, May 11, 2025
1:13 PM - 1:18 PM PT
Location: Monitor 9, Sails Pavilion, Upper Level

    ePoster Presenter(s)

  • Bennett W. Hartley, MD

    General Surgery Resident
    Baylor College of Medicine
    Houston, TX, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no financial relationships with ineligible companies.

    View ePoster

    • Author(s)

  • SK

    Stephanie Keeling, MD

    General Surgery Resident
    Baylor College of Medicine
    Houston, Texas, United States

    Disclosure information not submitted.

  • Atif Iqbal, MD, MS, FACS, FASCRS

    Chief of Colorectal Surgery, Assist. Vice Chair Quality
    Department of Surgery, Baylor College of Medicine, Houston, TX
    HOUSTON, TX, United States

    All of the relevant financial relationships listed below have been mitigated.
    This individual has no financial relationships with ineligible companies.

  • Yesenia Rojas-Khalil, MD, FACS (she/her/hers)

    Assistant Professor of Surgery
    Baylor College of Medicine
    Houston, Texas, United States

    Disclosure information not submitted.

  • Punam Amin, MD

    Colorectal surgeon
    Baylor College of Medicine, TX, United States

    Disclosure information not submitted.

  • DE

    Derek Erstad, MD

    Surgeon
    Baylor College of Medicine
    Houston, Texas, United States

    Disclosure information not submitted.

All of the relevant financial relationships listed below have been mitigated.
Bennett W. Hartley, MD: This individual has no financial relationships with ineligible companies.
Atif Iqbal, MD, MS, FACS, FASCRS: This individual has no financial relationships with ineligible companies.
Purpose/Background: Locally advanced (stage II & III) rectal cancer (LARC) was traditionally treated with neoadjuvant long course chemoradiation (CXRT) followed by surgery followed by adjuvant chemotherapy (AC). However, findings from multiple phase III clinical trials (RAPIDO, PRODIGE 23, STELLAR) support total neoadjuvant therapy (TNT) as first-line treatment for LARC, which NCCN introduced as a treatment option in 2016 and the preferred treatment in 2018. Using the National Cancer Database (NCDB), we investigated the real-world implementation, postoperative outcomes, and long-term survival of TNT compared to traditional CXRT from 2015-2020.

Methods/Interventions: Retrospective cohort study of 10,683 patients using NCDB (2015-2020). Cohort included patients with Stage II or III pMMR LARC who underwent one of two treatment options: 1) TNT followed by surgery, or 2) standard CXRT followed by surgery followed by AC . TNT group included 5,638 patients and XRT group included 5,045 patients. TNT & XRT groups were directly compared on outcomes including annual implementation of TNT & XRT, 30- & 90-day mortality, 30-day readmission, onset of treatment, hospital length of stay, surgical approach, R0 resection, downstaging, and positive lymph node ratio. Long-term survival was assessed using Kaplan-Meier curve and propensity matching was performed. T-test and chi-square statistical testing were performed.

Results/Outcomes: From 2015 to 2020, TNT utilization for LARC increased and standard pre-operative chemoradiation followed by adjuvant chemotherapy decreased. In 2015, 3.77% of patients underwent TNT + surgery and 15.90% underwent CXRT + surgery + AC. In 2020, 29.47% of LARC underwent TNT + surgery and 7.58% underwent CXRT + surgery + AC. 90-day postoperative mortality was 0.92% for TNT and 0.46% for CXRT (p = 0.011). Time from diagnosis to initiation of treatment was 39 days for TNT and 38 days for CXRT (p = 0.54). Average postoperative length of stay was 5.5 days for TNT and 5.0 days for CXRT (p = 0.59). Regarding procedure type (low anterior resection vs. abdominoperineal resection), 64.0% of TNT and 65.9% of CXRT patients underwent an LAR (p = 0.041) and 22.5% of TNT and 22.6% of CXRT patients underwent APR (p = 0.913). Margin-negative (R0) resection rates were 93.5% for TNT and 94.2% for XRT patients (p = 0.094). Pathologic downstaging was 16.87% for TNT patients and 39.96% for CXRT patients (p < 0.001). Positive lymph node ratio (LNR) was 6.14% for TNT and 8.71% for XRT patients (p = 0.026). TNT and CXRT cohorts demonstrated similar overall survival with no statistical difference in survival curves (p = 0.52) and similar 3-year survivals of 89.7% (95% CI 88.5-90.8%) for TNT and 89.2% (95% CI 88.2-90.1%) for CXRT. Similar results were found after propensity matching.

Conclusion/Discussion: We observed a significant increase in the use of TNT for LARC from 2015-2020. In comparison to the historical standard of preoperative chemoradiation, TNT patients had similar post-treatment clinicopathologic traits, perioperative outcomes, and long-term survival.

Total Neoadjuvant Therapy + Surgery vs. Chemoradiaion + Surgery + Adjuvant Chemotherapy for Stage II & III pMMR Rectal Cancer (2015-2020)
Trends in utilization for total neoadjuvant therapy + surgery and chemoradiation + surgery + adjuvant chemotherapy from 2015-2020

Locally Advanced Rectal Cancer Survival (2015-2020): Total Neoadjuvant Therapy + Surgery vs. Chemoradiation + Surgery + Adjuvant Chemotherapy
Overall survival for locally advanced rectal cancer receiving total neoadjuvant therapy + surgery or chemoradiation + surgery + adjuvant chemotherapy