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Adjuvant Chemotherapy Improves Survival Following Resection of Locally Advanced Rectal Cancer with Pathologic Complete Response

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

Controversy exists over the use of adjuvant chemotherapy for locally advanced (stages II–III) rectal cancer (LARC) patients who demonstrate pathologic complete response (pCR) following neoadjuvant chemoradiation. We conducted a retrospective analysis to determine whether adjuvant chemotherapy imparts survival benefit among this population.

Methods

The National Cancer Database (NCDB) was queried to identify LARC patients with pCR following neoadjuvant chemoradiation. The cohort was stratified by receipt of adjuvant chemotherapy. Multiple imputation and a Cox proportional hazards model were employed to estimate the effect of adjuvant chemotherapy on overall survival.

Results

There were 24,418 patients identified in the NCDB with clinically staged II or III rectal cancer who received neoadjuvant chemoradiation. Of these, 5606 (23.0%) had pCR. Among patients with pCR, 1401 (25%) received adjuvant chemotherapy and 4205 (75%) did not. Patients who received adjuvant chemotherapy were slightly younger, more likely to have private insurance, and more likely to have clinically staged III disease, but did not differ significantly in comparison to patients who did not receive adjuvant chemotherapy with respect to race, sex, facility type, Charlson comorbidity score, histologic tumor grade, procedure type, length of stay, or rate of 30-day readmission following surgery. On adjusted analysis, receipt of adjuvant chemotherapy was associated with a lower risk of death at a given time compared to patients who did not receive adjuvant chemotherapy (HR 0.808; 95% CI 0.679–0.961; p = 0.016).

Conclusion

Supporting existing NCCN guidelines, the findings from this study suggest that adjuvant chemotherapy improves survival for LARC with pCR following neoadjuvant chemoradiation.

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Funding

This study was supported by institutional funds.

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Authors and Affiliations

  1. Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, 2817, Durham, NC, 27710, USA

    Megan C. Turner, Jeffrey E. Keenan, Brian C. Gulack, Daniel P. Nussbaum, Ehsan Benrashid, Christopher R. Mantyh & John Migaly

  2. Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA

    Christel N. Rushing & Terry Hyslop

  3. Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC, USA

    John H. Strickler

Authors
  1. Megan C. Turner
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  2. Jeffrey E. Keenan
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Contributions

All authors have contributed to the ideas, design, analysis of data, interpretation and messaging, and critical revision and given final approval of the manuscript.

MCT: data acquisition, interpretation, drafting and critical revisions, final approval, accountability agreement

JEK: conception, interpretation, drafting and critical revisions, final approval, accountability agreement

CNR: data acquisition, design/conception, analysis of data, interpretation, critical revisions, final approval, accountability agreement

BCG: interpretation, drafting and critical revisions, final approval, accountability agreement

DPN: interpretation, drafting and critical revisions, final approval, accountability agreement

EB: interpretation, drafting and critical revisions, final approval, accountability agreement

TH: data acquisition, design/conception, analysis of data, interpretation, critical revisions, supervision, final approval, accountability agreement

JHS: conception, interpretation, critical revisions, supervision, final approval, accountability agreement

CRM: conception, interpretation, critical revisions, supervision, final approval, accountability agreement

JM: conception, interpretation, critical revisions, supervision, final approval, accountability agreement

Corresponding author

Correspondence to Megan C. Turner.

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Conflict of Interest

The authors declare that they have no conflict of interest.

The NCDB is a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. The data used in this study are derived from a de-identified NCDB file. The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methodology employed, or the conclusions drawn from these data by the investigators.

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Turner, M.C., Keenan, J.E., Rushing, C.N. et al. Adjuvant Chemotherapy Improves Survival Following Resection of Locally Advanced Rectal Cancer with Pathologic Complete Response. J Gastrointest Surg 23, 1614–1622 (2019). https://doi.org/10.1007/s11605-018-04079-8

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