Neoadjuvant Radiotherapy Use in Locally Advanced Rectal Cancer at NCCN Member Institutions

Restricted access

Based on randomized data, neoadjuvant chemoradiotherapy has been incorporated into the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for stage II-III rectal cancer. Factors associated with nonadherence to evidence-based guidelines for neoadjuvant radiotherapy (RT) were examined at dedicated cancer centers. The prospective NCCN Oncology Outcomes Database for Colorectal Cancers was queried for patients with stage II-III rectal cancer who underwent a transabdominal surgical resection between September 2005 and June 2012. Multivariable logistic regression was used to identify factors associated with omission of RT. Among 1199 identified patients, 1119 (93%) received neoadjuvant RT, 51 (4%) did not receive RT, and 29 (2%) received adjuvant RT. Among 51 patients not receiving RT, only 19 (37%) were referred and evaluated by a radiation oncologist. On multivariable analysis, clinical factors associated with not receiving RT included a history of prior pelvic RT (adjusted odds ratio [aOR], 23.9; P=.0003), ECOG performance status of 2 or greater (aOR, 11.1; P=.01), tumor distance from the anal verge greater than 10 cm (aOR, 5.4; P=.009), age at diagnosis of 75 years or older (aOR, 4.43; P=.002), body mass index of 25 to 30 kg/m2 and less than 25 kg/m2 (aOR, 5.22 and 4.23, respectively; P=.03), and clinical stage II (aOR, 2.27; P=.02). No significant change was seen in RT use according to diagnosis year, nor was any correlation seen with distance to the nearest RT facility. Concordance with NCCN Guidelines for neoadjuvant RT is high among NCCN Member Institutions. After adjusting for clinical characteristics that increase the risk for RT toxicity, including history of pelvic RT and high comorbidity burden/low functional status, the authors found that non-obese patients of advanced age or those with more favorable clinical features were more likely to not receive RT.

Correspondence: Karyn A. Goodman, MD, MS, Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065. E-mail: goodmank@mskcc.org
  • 1.

    EnkerWEThalerHTCranorML. Total mesorectal excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg1995;181:335346.

    • Search Google Scholar
    • Export Citation
  • 2.

    FolkessonJBirgissonHPahlmanL. Swedish Rectal Cancer Trial: long lasting benefits from radiotherapy on survival and local recurrence rate. J Clin Oncol2005;23:56445650.

    • Search Google Scholar
    • Export Citation
  • 3.

    KapiteijnEMarijnenCANagtegaalID. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med2001;345:638646.

    • Search Google Scholar
    • Export Citation
  • 4.

    PeetersKCMarijnenCANagtegaalID. The TME trial after a median follow-up of 6 years: increased local control but no survival benefit in irradiated patients with resectable rectal carcinoma. Ann Surg2007;246:693701.

    • Search Google Scholar
    • Export Citation
  • 5.

    CammaCGiuntaMFioricaF. Preoperative radiotherapy for resectable rectal cancer: a meta-analysis. JAMA2000;284:10081015.

  • 6.

    DouglassHOJrMoertelCGMayerRJ. Survival after postoperative combination treatment of rectal cancer. N Engl J Med1986;315:12941295.

  • 7.

    Prolongation of the disease-free interval in surgically treated rectal carcinoma. Gastrointestinal Tumor Study Group. N Engl J Med1985;312:14651472.

    • Search Google Scholar
    • Export Citation
  • 8.

    ZoccaliMFicheraA. Role of radiation in intermediate-risk rectal cancer. Ann Surg Oncol2012;19:126130.

  • 9.

    GerardJPConroyTBonnetainF. Preoperative radiotherapy with or without concurrent fluorouracil and leucovorin in T3-4 rectal cancers: results of FFCD 9203. J Clin Oncol2006;24:46204625.

    • Search Google Scholar
    • Export Citation
  • 10.

    ChauIBrownGCunninghamD. Neoadjuvant capecitabine and oxaliplatin followed by synchronous chemoradiation and total mesorectal excision in magnetic resonance imaging-defined poor-risk rectal cancer. J Clin Oncol2006;24:668674.

    • Search Google Scholar
    • Export Citation
  • 11.

    SauerRBeckerHHohenbergerW. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med2004;351:17311740.

  • 12.

    BensonABIIIVenookAPBekaii-SaabT. NCCN Clinical Practice Guidelines in Oncology for Rectal Cancer. Version 2 2014. Available at: NCCN.org. Accessed January 16 2014.

    • Search Google Scholar
    • Export Citation
  • 13.

    DeschCEMcNiffKKSchneiderEC. American Society of Clinical Oncology/National Comprehensive Cancer Network quality measures. J Clin Oncol2008;26:36313637.

    • Search Google Scholar
    • Export Citation
  • 14.

    CharlsonMEPompeiPAlesKL. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis1987;40:373383.

    • Search Google Scholar
    • Export Citation
  • 15.

    AssociationAH. 2008 American Hospital Association Annual Survey of Hospitals. Chicago; 2008.

  • 16.

    RohMSColangeloLHO’ConnellMJ. Preoperative multimodality therapy improves disease-free survival in patients with carcinoma of the rectum: NSABP R-03. J Clin Oncol2009;27:51245130.

    • Search Google Scholar
    • Export Citation
  • 17.

    ParkJHYoonSMYuCS. Randomized phase 3 trial comparing preoperative and postoperative chemoradiotherapy with capecitabine for locally advanced rectal cancer. Cancer2011;117:37033712.

    • Search Google Scholar
    • Export Citation
  • 18.

    KuoIWongJHRoy-ChowdhuryS. The use of pelvic radiation in stage II rectal cancer: a population-based analysis. Am Surg2010;76:10921095.

    • Search Google Scholar
    • Export Citation
  • 19.

    MakRHMcCarthyEPDasP. Adoption of preoperative radiation therapy for rectal cancer from 2000 to 2006: a Surveillance, Epidemiology, and End Results patterns-of-care study. Int J Radiat Oncol Biol Phys2011;80:978984.

    • Search Google Scholar
    • Export Citation
  • 20.

    BaxterNNRothenbergerDAMorrisAM. Adjuvant radiation for rectal cancer: do we measure up to the standard of care?An epidemiologic analysis of trends over 25 years in the United States. Dis Colon Rectum2005;48:915.

    • Search Google Scholar
    • Export Citation
  • 21.

    AyanianJZZaslavskyAMFuchsCS. Use of adjuvant chemotherapy and radiation therapy for colorectal cancer in a population-based cohort. J Clin Oncol2003;21:12931300.

    • Search Google Scholar
    • Export Citation
  • 22.

    MorrisAMWeiYBirkmeyerNJ. Racial disparities in late survival after rectal cancer surgery. J Am Coll Surg2006;203:787794.

  • 23.

    InHNevilleBALipsitzSR. The role of National Cancer Institute-designated cancer center status: observed variation in surgical care depends on the level of evidence. Ann Surg2012;255:890895.

    • Search Google Scholar
    • Export Citation
  • 24.

    NeugutAIFleischauerATSundararajanV. Use of adjuvant chemotherapy and radiation therapy for rectal cancer among the elderly: a population-based study. J Clin Oncol2002;20:26432650.

    • Search Google Scholar
    • Export Citation
  • 25.

    SchragDGelfandSEBachPB. Who gets adjuvant treatment for stage II and III rectal cancer? Insight from Surveillance, Epidemiology, and End Results—Medicare. J Clin Oncol2001;19:37123718.

    • Search Google Scholar
    • Export Citation
  • 26.

    DobieSAWarrenJLMatthewsB. Survival benefits and trends in use of adjuvant therapy among elderly stage II and III rectal cancer patients in the general population. Cancer2008;112:789799.

    • Search Google Scholar
    • Export Citation
  • 27.

    GundersonLLSargentDJTepperJE. Impact of T and N stage and treatment on survival and relapse in adjuvant rectal cancer: a pooled analysis. J Clin Oncol2004;22:17851796.

    • Search Google Scholar
    • Export Citation
  • 28.

    HowardJHGonzalezQArnolettiJP. Prognostic factors and preoperative radiation therapy associated with sphincter preservation in patients with resectable rectal cancer. Am J Surg2008;195:239243.

    • Search Google Scholar
    • Export Citation
  • 29.

    MeyerhardtJATepperJENiedzwieckiD. Impact of body mass index on outcomes and treatment-related toxicity in patients with stage II and III rectal cancer: findings from Intergroup Trial 0114. J Clin Oncol2004;22:648657.

    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 89 89 12
PDF Downloads 9 9 0
EPUB Downloads 0 0 0