Abstract
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. 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. Three RCTs, with a total of 357 rectal cancer patients, were included in this systematic review. Meta- analysis 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]. 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.
Highlights
Long-course chemo-radiotherapy (45~50 Gy in 25 fractions) with delayed surgery or short-course radiotherapy (25 Gy in 5 fractions) with immediate surgery were the most frequent regimens for the treatment of localized and locally advanced resectable rectal cancer (SWEDISH RECTAL CANCER TRIAL, 1997; Colorectal Cancer Collaborative Group, 2001; Kapiteijn et al, 2001; Sauer et al, 2004)
Compared with Short-course preoperative radiation (SCRT), long-course chemo-radiotherapy (LCRT) was associated with significant increase in the pathologic complete response (pCR) rate [risk ratios (RRs)=0.49, 95%confidence intervals (CIs) (0.31, 0.78), P=0.003]
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
Summary
Long-course chemo-radiotherapy (45~50 Gy in 25 fractions) with delayed surgery or short-course radiotherapy (25 Gy in 5 fractions) with immediate surgery were the most frequent regimens for the treatment of localized and locally advanced resectable rectal cancer (SWEDISH RECTAL CANCER TRIAL, 1997; Colorectal Cancer Collaborative Group, 2001; Kapiteijn et al, 2001; Sauer et al, 2004). Long-course preoperative chemo-radiotherapy (LCRT) of 50.4 Gy in about 6 weeks with delayed surgery has been widely used in the last decades, which superiority, in terms of local control, was demonstrated in the German rectal cancer trial, compared with postoperative chemo-radiotherapy (Sauer et al, 2004; Sauer et al, 2012). There was no clear answer on whether SCRT or long-course chemo-radiotherapy (LCRT) is more effective We conducted this meta-analysis to evaluate the safety and efficacy of SCRT versus LCRT, both with delayed surgery, for treatment of rectal cancer. 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. Due to risk of bias and imprecision, further multi-center large sample RCTs were needed to confirm this conclusion
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