Utilization of short-course radiation therapy for patients with nonmetastatic rectal adenocarcinoma in the United States

Abstract

PurposePreoperative short-course radiation therapy (SCRT) for patients with nonmetastatic rectal adenocarcinoma has been studied in European trials, but is not often used in the United States. We aim to describe the utilization of preoperative SCRT among patients with nonmetastatic rectal cancer in the National Cancer Database and describe factors associated with its use.Methods and materialsThe National Cancer Database was queried for patients treated with preoperative radiation therapy followed by surgery for nonmetastatic rectal adenocarcinoma between 2004 and 2014. Patient, tumor, and treatment-related characteristics were compared between patients treated with SCRT (20-25 Gy in <7 fractions) and patients treated with long-course radiation therapy (45-70 Gy in ≥ 25 fractions). Univariate and multivariate Cox regression analyses were used to evaluate factors associated with overall survival. Survival rates were compared using an inverse-probability-weighted regression adjustment method.ResultsA total of 42,336 patients were included for analysis of which 41,867 patients (98.9%) were treated with long-course radiation therapy and 469 patients (1.1%) with SCRT. Patients treated with SCRT were older, had more comorbidities, had earlier T-stage, and were more likely to be clinically node-negative. Patients treated with SCRT were more likely to be treated at an academic center, have Medicare insurance, and be treated without chemotherapy. Patients treated with SCRT had lower pathological complete response rates (4.3% vs 6.9%; P < .001) and higher rates of positive circumferential resection margins (8.3% vs 5.2%; P = .001). On multivariate analysis, radiation fractionation was not significantly associated with overall survival.ConclusionsSCRT is used for only approximately 1% of patients treated preoperatively for nonmetastatic rectal cancer in the United States. The results of recently completed randomized trials may further inform patterns of practice in the United States and abroad.

Cost-effectiveness of Total Neoadjuvant Therapy With Short-Course Radiotherapy for Resectable Locally Advanced Rectal Cancer

“…At present, SCRT is underused (<1%) in the US, 46 but it is gaining traction in the setting of increased interest in shortening treatment in the setting of the COVID-19 pandemic. 47 Previous studies have suggested that SCRT might be less efficacious with less tumor downstaging compared with LCCRT 48 and might result in more acute toxic effects.…”

Cost-effectiveness of Total Neoadjuvant Therapy With Short-Course Radiotherapy for Resectable Locally Advanced Rectal Cancer

“…At present, SCRT is underused (<1%) in the US, 46 but it is gaining traction in the setting of increased interest in shortening treatment in the setting of the COVID-19 pandemic. 47 Previous studies have suggested that SCRT might be less efficacious with less tumor downstaging compared with LCCRT 48 and might result in more acute toxic effects.…”

Nonoperative Management Following Complete Response in Rectal Cancer After Short-course Radiation Therapy and Consolidation Chemotherapy

“…Although the utilization of SCRT for rectal cancer has been reported as 1% in the United States, this number comes from an era (2004-2014) before RAPIDO. 35 Therefore, we expect the utilization of SCRT for locally advanced rectal cancer to rise due to improvement in patient/provider convenience, shorter treatment duration, and cost-effectiveness. 36,37 Another important finding from PRODIGE 23 and RAP-IDO was the impressive pathologic CR rates in the TNT groups -28% in both studies.…”

“…RAPIDO did not answer the question regarding the relative value of SCRT versus LC-CRT in the TNT setting but it does provide valuable findings on the efficacy and feasibility of SCRT in the TNT setting. Although the utilization of SCRT for rectal cancer has been reported as 1% in the United States, this number comes from an era (2004-2014) before RAPIDO 35. Therefore, we expect the utilization of SCRT for locally advanced rectal cancer to rise due to improvement in patient/provider convenience, shorter treatment duration, and cost-effectiveness 36,37…”

Phase II Trial of Neoadjuvant Bevacizumab with Modified FOLFOX7 in Patients with Stage II and III Rectal Cancer

“…Surgery remains the mainstay of cure in patients with rectal cancer with resectable disease, whereas radiation and chemotherapy reduce the chances of local and systemic recurrence [7,8]. Neoadjuvant chemoradiation followed by surgery and subsequent adjuvant chemotherapy has been established as the standard of care in the U.S. [9,10]. Although chemoradiation has been beneficial in reducing local recurrence, it does not confer overall survival (OS) benefit, and risk of systemic recurrence in most patients with rectal cancer remains higher than local recurrence [11][12][13].…”

Cost-effectiveness of Total Neoadjuvant Therapy With Short-Course Radiotherapy for Resectable Locally Advanced Rectal Cancer

“…At present, SCRT is underused (<1%) in the US, 46 but it is gaining traction in the setting of increased interest in shortening treatment in the setting of the COVID-19 pandemic. 47 Previous studies have suggested that SCRT might be less efficacious with less tumor downstaging compared with LCCRT 48 and might result in more acute toxic effects.…”

Nonoperative Management Following Complete Response in Rectal Cancer After Short-course Radiation Therapy and Consolidation Chemotherapy

“…Although the utilization of SCRT for rectal cancer has been reported as 1% in the United States, this number comes from an era (2004-2014) before RAPIDO. 35 Therefore, we expect the utilization of SCRT for locally advanced rectal cancer to rise due to improvement in patient/provider convenience, shorter treatment duration, and cost-effectiveness. 36,37 Another important finding from PRODIGE 23 and RAP-IDO was the impressive pathologic CR rates in the TNT groups -28% in both studies.…”

“…RAPIDO did not answer the question regarding the relative value of SCRT versus LC-CRT in the TNT setting but it does provide valuable findings on the efficacy and feasibility of SCRT in the TNT setting. Although the utilization of SCRT for rectal cancer has been reported as 1% in the United States, this number comes from an era (2004-2014) before RAPIDO 35. Therefore, we expect the utilization of SCRT for locally advanced rectal cancer to rise due to improvement in patient/provider convenience, shorter treatment duration, and cost-effectiveness 36,37…”

Phase II Trial of Neoadjuvant Bevacizumab with Modified FOLFOX7 in Patients with Stage II and III Rectal Cancer

“…Surgery remains the mainstay of cure in patients with rectal cancer with resectable disease, whereas radiation and chemotherapy reduce the chances of local and systemic recurrence [7,8]. Neoadjuvant chemoradiation followed by surgery and subsequent adjuvant chemotherapy has been established as the standard of care in the U.S. [9,10]. Although chemoradiation has been beneficial in reducing local recurrence, it does not confer overall survival (OS) benefit, and risk of systemic recurrence in most patients with rectal cancer remains higher than local recurrence [11][12][13].…”

Cost-effectiveness of Total Neoadjuvant Therapy With Short-Course Radiotherapy for Resectable Locally Advanced Rectal Cancer

“…At present, SCRT is underused (<1%) in the US, 46 but it is gaining traction in the setting of increased interest in shortening treatment in the setting of the COVID-19 pandemic. 47 Previous studies have suggested that SCRT might be less efficacious with less tumor downstaging compared with LCCRT 48 and might result in more acute toxic effects.…”

Nonoperative Management Following Complete Response in Rectal Cancer After Short-course Radiation Therapy and Consolidation Chemotherapy

“…Although the utilization of SCRT for rectal cancer has been reported as 1% in the United States, this number comes from an era (2004-2014) before RAPIDO. 35 Therefore, we expect the utilization of SCRT for locally advanced rectal cancer to rise due to improvement in patient/provider convenience, shorter treatment duration, and cost-effectiveness. 36,37 Another important finding from PRODIGE 23 and RAP-IDO was the impressive pathologic CR rates in the TNT groups -28% in both studies.…”

“…RAPIDO did not answer the question regarding the relative value of SCRT versus LC-CRT in the TNT setting but it does provide valuable findings on the efficacy and feasibility of SCRT in the TNT setting. Although the utilization of SCRT for rectal cancer has been reported as 1% in the United States, this number comes from an era (2004-2014) before RAPIDO 35. Therefore, we expect the utilization of SCRT for locally advanced rectal cancer to rise due to improvement in patient/provider convenience, shorter treatment duration, and cost-effectiveness 36,37…”

Phase II Trial of Neoadjuvant Bevacizumab with Modified FOLFOX7 in Patients with Stage II and III Rectal Cancer

“…Surgery remains the mainstay of cure in patients with rectal cancer with resectable disease, whereas radiation and chemotherapy reduce the chances of local and systemic recurrence [7,8]. Neoadjuvant chemoradiation followed by surgery and subsequent adjuvant chemotherapy has been established as the standard of care in the U.S. [9,10]. Although chemoradiation has been beneficial in reducing local recurrence, it does not confer overall survival (OS) benefit, and risk of systemic recurrence in most patients with rectal cancer remains higher than local recurrence [11][12][13].…”