Comment on "Neoadjuvant Chemotherapy With CAPOX Versus Chemoradiation for Locally Advanced Rectal Cancer With Uninvolved Mesorectal Fascia (CONVERT): Initial Results of a Phase III Trial" by Mei et al.: Two Overtreatments Compared.

Abstract

Mei et al. published in Annals of Surgery1 the initial results of the CONVERT trial, comparing neoadjuvant chemotherapy with CAPOX versus standard chemoradiation for rectal cancer with uninvolved mesorectal fascia. The design of the study, reported results and conclusions raise concerns. It seems that a vast majority of the cohort did experience an overtreatment, as their tumors could be adequately treated with surgery alone.2,3 The authors do not discuss these limitations, nor have they reported, whether surgery alone was one of the options given to patients during the consent process. It is not clear, what was the benefit of neoadjuvant treatment in patients with primary operable tumors. The price of this treatment is mentioned. Despite relatively young (median age of 60 years, age limit 75 years) and healthy cohort (ECOG performance status ≤1, adequate hematologic, liver, and renal function), 70.3% in the neoadjuvant chemotherapy group and 64.7% in the neoadjuvant chemoradiotherapy group experienced toxicities. The postoperative morbidity was 18.8% and 25.7%, respectively. Nearly 10% in both groups did not receive surgery at all, and 13% refused postoperative therapy. The authors describe the downstaging of the tumors, but without admitting that the reliability of comparison between MRI and pathological findings is low.4–6 Post-treatment functional impairment, frequency, and severity of low anterior syndrome are also not reported. A statistical comparison of 2 overtreatments does not make the treatment appropriate. All treatment modalities in rectal cancer: surgery, radiotherapy, and chemotherapy do have a significant risk of complication. The combination of these treatment options could possibly potentiate their risks and adverse effects; therefore, selecting the therapy course is a difficult and careful process. The goal is to find a minimal therapy sufficient for success, not a maximal therapy applicable to the patient.