In an analysis of National Cancer Database data reported in JAMA Surgery, Nassoiy et al found that neoadjuvant chemoradiation therapy followed by surgery was associated with higher rates of R0 resection and improved survival vs other treatments in patients aged 80 and older undergoing surgery for locally advanced rectal cancer.
As stated by the investigators: “The number of older patients diagnosed with locally advanced rectal cancer is expected to increase. Although current guidelines recommend neoadjuvant chemoradiation therapy followed by resection, little is known about management and outcomes in this older population.”
Study Details
In the study, patients aged 80 and older undergoing surgical resection for locally advanced rectal cancer were identified from the 2004–2016 National Cancer Database. Patients were grouped according to therapy: surgery followed by adjuvant chemotherapy or radiation therapy; surgery alone; or neoadjuvant chemoradiation therapy followed by surgery. Overall survival was assessed by Kaplan-Meier analysis with inverse probability of treatment weighting (IPTW).
Key Findings
Among 3,868 patients included in the analysis, 2,273 (58.8%) received neoadjuvant chemoradiation therapy followed by surgery, 404 (10.4%) underwent surgery and then received adjuvant therapy, and 1,191 (30.1%) underwent surgery alone.
Factors independently associated with receipt of neoadjuvant chemoradiation therapy were more recent diagnosis, age 80 to 85 years vs ≥ 86 years, fewer comorbidities, larger tumors, and node-positive disease.
On Kaplan-Meier analyses with IPTW, median overall survival was 5.11 years with neoadjuvant chemoradiation therapy followed by surgery, 4.19 years with surgery plus adjuvant therapy, and 3.45 years with surgery alone (overall P < .001). Rates at 3 and 5 years were 68.9% and 51.1%, 64.4% and 43.0%, and 55.8% and 34.7%, respectively. On multivariate analysis, neoadjuvant chemoradiation therapy plus surgery was associated with a significantly reduced risk of death vs other treatments (hazard ratio [HR] = 0.75, 95% confidence interval [CI] = 0.69–0.82, P < .001).
On multivariate analysis, patients who received neoadjuvant chemoradiation therapy were more likely to achieve R0 resection compared with patients undergoing surgery plus adjuvant therapy or surgery alone (adjusted odds ratio = 2.16, 95% CI = 1.62–2.88). Achievement of R0 resection was independently associated with improved overall survival (HR = 0.71, 95% CI = 0.61–0.83, P < .001).
The investigators concluded: “Approximately 40% of older patients with locally advanced rectal cancer did not receive the current standard of care. In this cohort, neoadjuvant chemoradiation therapy was associated with a higher likelihood of an R0 resection and improved overall survival. Clinicians should advocate for receipt of neoadjuvant chemoradiation therapy in older patients with locally advanced rectal cancer.”
Melanie Goldfarb, MD, MSc, of Providence Saint John’s Cancer Institute, Santa Monica, is the corresponding author of the JAMA Surgery article.
Disclosure: For full disclosures of the study authors, visit jamanetwork.com.
