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Short-course Versus Long-course Preoperative Radiotherapy plus Delayed Surgery in the Treatment of Rectal Cancer: a Meta-analysis

  • Liu, Shi-Xin (Department of Radiation Oncology, Tumor Hospital of Jilin Province) ;
  • Zhou, Zhi-Rui (Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University) ;
  • Chen, Ling-Xiao (Department of Orthopaedics, Tianjin Medical University General Hospital) ;
  • Yang, Yong-Jing (Department of Radiation Oncology, Tumor Hospital of Jilin Province) ;
  • Hu, Zhi-De (Department of Laboratory Medicine, General Hospital of Ji'nan Military Command Region) ;
  • Zhang, Tian-Song (Internal Medicine of Traditional Chinese Medicine Department, Jing'an District Central Hospital of Shanghai)
  • Published : 2015.09.02

Abstract

Background: Short-course preoperative radiation (SCRT) with delayed surgery was found to increase pathologic complete response (pCR) rates in several trials. However, there was no clear answer on whether SCRT or long-course chemo-radiotherapy (LCRT) is more effective. Therefore we conducted this meta-analysis to evaluate the safety and efficacy of SCRT versus LCRT, both with delayed surgery, for treatment of rectal cancer. Materials and Methods: The literature was searched from PubMed, EMBASE, Web of Science, Cochrane Library and clinicaltrials.gov up to November, 2014. Quality of the randomized controlled trials (RCTs) was evaluated according to the Cochrane's risk of bias tool of RCT. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to rate the level of evidence. Review Manager 5.3 was employed for statistical analysis. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated. Results: Three RCTs, with a total of 357 rectal cancer patients, were included in this systematic review. Metaanalysis results demonstrated there were no significantly differences in sphincter preservation rate, local recurrence rate, grade 3~4 acute toxicity, R0 resection rate and downstaging rate. Compared with SCRT, LCRT was associated with significant increase in the pCR rate [RR=0.49, 95%CI (0.31, 0.78), P=0.003]. Conclusions: In terms of sphincter preservation rate, local recurrence rate, grade 3~4 acute toxicity, R0 resection rate and downstaging rate, SCRT with delayed surgery is as effective as LCRT with delayed surgery for management of rectal cancer. LCRT significantly increased pCR rate compared with SCRT. Due to risk of bias and imprecision, further multi-center large sample RCTs were needed to confirm this conclusion.

References

  1. Balshem H, Helfand M, Schunemann HJ, et al (2011). GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol, 64, 401-6. https://doi.org/10.1016/j.jclinepi.2010.07.015
  2. Borenstein M, Hedges LV, Higgins JPT, et al 2009. Introduction to Meta-Analysis, John Wiley & Sons, Ltd.
  3. Bujko K, Bujko M (2011). Point: short-course radiation therapy is preferable in the neoadjuvant treatment of rectal cancer. Semin Radiat Oncol, 21, 220-7. https://doi.org/10.1016/j.semradonc.2011.02.008
  4. Bujko K, Nowacki MP, Nasierowska-Guttmejer A, et al (2006). Long-term results of a randomized trial comparing preoperative short-course radiotherapy with preoperative conventionally fractionated chemoradiation for rectal cancer. Br J Surg, 93, 1215-23. https://doi.org/10.1002/bjs.5506
  5. Bujko K, Partycki M, Pietrzak L (2014). Neoadjuvant radiotherapy (5 x 5 Gy): immediate versus delayed surgery. Recent Results Cancer Res, 203, 171-87. https://doi.org/10.1007/978-3-319-08060-4_12
  6. Bujko K, Richter P, Smith FM, et al (2013). Preoperative radiotherapy and local excision of rectal cancer with immediate radical re-operation for poor responders: A prospective multicentre study. Radiotherapy Oncol, 106, 198-205. https://doi.org/10.1016/j.radonc.2012.12.005
  7. Frykholm GJ, Glimelius B, Pahlman L (1993). Preoperative or postoperative irradiation in adenocarcinoma of the rectum: final treatment results of a randomized trial and an evaluation of late secondary effects. Dis Colon Rectum, 36, 564-72. https://doi.org/10.1007/BF02049863
  8. Colorectal Cancer Collaborative Group (2001). Adjuvant radiotherapy for rectal cancer: a systematic overview of 8,507 patients from 22 randomised trials. Lancet, 358, 1291-304. https://doi.org/10.1016/S0140-6736(01)06409-1
  9. Guyatt GH, Oxman AD, Kunz R, et al (2011a). GRADE guidelines 6. Rating the quality of evidence-imprecision. J Clin Epidemiol, 64, 1283-93. https://doi.org/10.1016/j.jclinepi.2011.01.012
  10. Guyatt GH, Oxman AD, Vist G, et al (2011b). GRADE guidelines: 4. Rating the quality of evidence--study limitations (risk of bias). J Clin Epidemiol, 64, 407-15. https://doi.org/10.1016/j.jclinepi.2010.07.017
  11. Guyatt GH, Oxman AD, Vist G, et al (2011c). GRADE guidelines: 4. Rating the quality of evidence-study limitations (risk of bias). J Clin Epidemiol, 64, 407-15. https://doi.org/10.1016/j.jclinepi.2010.07.017
  12. Hatfield P, Hingorani M, Radhakrishna G, et al (2009). Shortcourse radiotherapy, with elective delay prior to surgery, in patients with unresectable rectal cancer who have poor performance status or significant co-morbidity. Radiother Oncol, 92, 210-4. https://doi.org/10.1016/j.radonc.2009.04.007
  13. Higgins JPT, Green S (2011). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. Available from www.cochrane-handbook.org.
  14. Kapiteijn E, Marijnen CA, Nagtegaal ID, et al (2001). Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med, 345, 638-46. https://doi.org/10.1056/NEJMoa010580
  15. Kye BH, Cho HM (2014). Overview of radiation therapy for treating rectal cancer. Ann Coloproctol, 30, 165-74. https://doi.org/10.3393/ac.2014.30.4.165
  16. Latkauskas T, Pauzas H, Gineikiene I, et al (2012). Initial results of a randomized controlled trial comparing clinical and pathological downstaging of rectal cancer after preoperative short-course radiotherapy or long-term chemoradiotherapy, both with delayed surgery. Colorectal Dis, 14, 294-8. https://doi.org/10.1111/j.1463-1318.2011.02815.x
  17. Lee WC, Yusof MM, Lau FN, et al (2013). Preoperative long course chemoirradiation in a developing country for rectal carcinoma: Kuala Lumpur hospital experience. Asian Pac J Cancer Prev, 14, 3941-4. https://doi.org/10.7314/APJCP.2013.14.6.3941
  18. Minsky BD (2011). Counterpoint: long-course chemoradiation is preferable in the neoadjuvant treatment of rectal cancer. Semin Radiat Oncol, 21, 228-33. https://doi.org/10.1016/j.semradonc.2011.02.009
  19. Minsky BD, Rodel C, Valentini V (2014). Preoperative therapy for rectal cancer: Short-course radiation vs. long-course chemoradiation. Seminars Colon Rectal Surgery, 25, 19-21. https://doi.org/10.1053/j.scrs.2013.09.004
  20. Nilsson PJ, van Etten B, Hospers GAP, et al (2013). Short-course radiotherapy followed by neo-adjuvant chemotherapy in locally advanced rectal cancer - the RAPIDO trial. BMC Cancer, 13.
  21. Palta M, Willett CG, Czito BG (2014). Short-Course versus Long-Course Chemoradiation in Rectal Cancer-Time to Change Strategies? Curr Treat Options Oncol, [Epub ahead of print].
  22. Pettersson D, Cedermark B, Holm T, et al (2010). Interim analysis of the Stockholm III trial of preoperative radiotherapy regimens for rectal cancer. Br J Surg, 97, 580-7. https://doi.org/10.1002/bjs.6914
  23. Radu C, Berglund A, Pahlman L, et al (2008). Short-course preoperative radiotherapy with delayed surgery in rectal cancer - a retrospective study. Radiother Oncol, 87, 343-9. https://doi.org/10.1016/j.radonc.2007.11.025
  24. Rodel C, Trojan J, Bechstein WO, et al (2012). Neoadjuvant short- or long-term radiochemotherapy for rectal cancer: how and who should be treated? Dig Dis, 30, 102-8. https://doi.org/10.1159/000342038
  25. Sajid MS, Siddiqui MR, Kianifard B, et al (2010). Short-course versus long-course neoadjuvant radiotherapy for lower rectal cancer: a systematic review. Ir J Med Sci, 179, 165-71. https://doi.org/10.1007/s11845-009-0382-9
  26. Sauer R, Becker H, Hohenberger W, et al (2004). Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med, 351, 1731-40. https://doi.org/10.1056/NEJMoa040694
  27. Sauer R, Liersch T, Merkel S, et al (2012). Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 randomized phase III trial after a median follow-up of 11 years. J Clin Oncol, 30, 1926-33. https://doi.org/10.1200/JCO.2011.40.1836
  28. Sebag-Montefiore D, Stephens RJ, Steele R, et al (2009). Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial. Lancet, 373, 811-20. https://doi.org/10.1016/S0140-6736(09)60484-0
  29. SWEDISH RECTAL CANCER TRIAL (1997). Improved survival with preoperative radiotherapy in resectable rectal cancer. N Engl J Med, 336, 980-7. https://doi.org/10.1056/NEJM199704033361402
  30. Zhou ZR, Liu SX, Zhang TS, et al (2014). Short-course preoperative radiotherapy with immediate surgery versus long-course chemoradiation with delayed surgery in the treatment of rectal cancer: a systematic review and metaanalysis. Surg Oncol, 23, 211-21. https://doi.org/10.1016/j.suronc.2014.10.003

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