Correspondence
Adjuvant chemotherapy for rectal cancer We read with interest the metaanalysis1 by Anne Breugom and colleagues about the role of adjuvant chemotherapy for patients with locally advanced rectal cancer treated with preoperative (chemo)radiotherapy. Adjuvant fluorouracil-based chemotherapy was found not to improve overall survival, disease-free survival, or distant recurrences for patients with rectal cancer receiving neoadjuvant treatment. The authors stated that noncompliance to adjuvant chemotherapy was a serious problem in studies of adjuvant chemotherapy in patients with rectal cancer after preoperative (chemo)radiotherapy and surgery; less than 50% of the patients in the EORTC 22921 trial2 and CHRONICLE trial3 completed all cycles of chemotherapy. Thus, there is a possibility that survival in patients receiving adjuvant chemotherapy was no better than in patients who did not because they received inadequate courses of adjuvant chemotherapy. It is important that the authors, if possible, compare survival of patients who received the full course of adjuvant chemotherapy with that of patients who underwent observation. Furthermore, the authors could compare the survival of patients who received inadequate cycles of adjuvant chemotherapy with that of patients who underwent observation. The patients included in the metaanalysis had ypNM stage II and III disease, and the specific compliance to adjuvant chemotherapy in this subgroup was unclear. In terms of disease-free survival and distant recurrence, the authors found that adjuvant chemotherapy might benefit patients with a tumour located 10–15 cm from the anal verge. It is not clear why 5-cm intervals were chosen to separate the different parts of the rectum and how www.thelancet.com/oncology Vol 16 April 2015
the authors found that the tumours located 10–15 cm from the anal verge benefited most from adjuvant chemotherapy. We think it is possible and more reasonable to acquire the optimal cut-off value through receiver operating characteristic curves or other methods when identifying who might really benefit from adjuvant chemotherapy. It would also be interesting to do further analysis of distant metastasis incidence in different part of the rectum, and then evaluate the true value of adjuvant chemotherapy. Some retrospective studies4,5 have shown that adjuvant chemotherapy might still be valuable for patients with rectal cancer treated with preoperative (chemo)radiotherapy, although these results contradict the conclusion by Breugom and colleagues.1 The contradictory findings suggest that there might be a subgroup of patients who would benefit from adjuvant chemotherapy, and the challenge now is to define this subgroup.4 We declare no competing interests.
Kai-yun You, Zhuo-fei Bi, *Yi-min Liu, Xing-sheng Qiu [email protected] Department of Radiation Oncology, SunYat-Sen Memorial Hospital, SunYat-Sen University, Guangdong, China 1
2
3
4
Breugom AJ, Swets M, Bosset JF. Adjuvant chemotherapy after preoperative (chemo) radiotherapy and surgery for patients with rectal cancer: a systematic review and metaanalysis of individual patient data. Lancet Oncol 2015; 16: 200–07. Glynne-Jones R, Counsell N, Quirke P, et al. Chronicle: results of a randomised phase III trial in locally advanced rectal cancer after neoadjuvant chemoradiation randomising postoperative adjuvant capecitabine plus oxaliplatin (XELOX) versus control. Ann Oncol 2014; 25: 1356–62. Bosset JF, Calais G, Mineur L, et al. Fluorouracil-based adjuvant chemotherapy after preoperative chemoradiotherapy in rectal cancer: long-term results of the EORTC 22921 randomised study. Lancet Oncol 2014; 15: 184–90. Maas M, Nelemans PJ, Valentini V, et al. Adjuvant chemotherapy in rectal cancer: defining subgroups who may benefit after neoadjuvant chemoradiation and resection. A pooled analysis of 3,313 patients. Int J Cancer 2014; published online Nov 22. DOI:10.1002/ijc.29355.
5
Geva R, Itzkovich E, Shamai S,et al. Is there a role for adjuvant chemotherapy in pathological complete response rectal cancer tumors following neoadjuvant chemoradiotherapy? J Cancer Res Clin Oncol 2014; 140: 1489–94.
The meta-analysis of individual patient data by Anne Breugom and colleagues,1 addressing the benefit of adjuvant chemotherapy after neoadjuvant (chemo)radiotherapy in patients with locally advanced rectal cancer, will probably extend the controversy and debate about this topic. This meta-analysis includes only patients with pathological (y)pTNM stage II–III disease, randomised to receive adjuvant chemotherapy or undergo observation after (chemo)radiotherapy and surgery. The investigators found a benefit of adjuvant chemotherapy in diseasefree survival only in those patients with tumours located more than 10 cm from the anal verge. Our meta-analysis of retrospective studies2 suggested that the 5-year survival benefit of adjuvant chemotherapy is relevant and significant (odds ratio 0·44, p
Adjuvant chemotherapy for rectal cancer We read with interest the metaanalysis1 by Anne Breugom and colleagues about the role of adjuvant chemotherapy for patients with locally advanced rectal cancer treated with preoperative (chemo)radiotherapy. Adjuvant fluorouracil-based chemotherapy was found not to improve overall survival, disease-free survival, or distant recurrences for patients with rectal cancer receiving neoadjuvant treatment. The authors stated that noncompliance to adjuvant chemotherapy was a serious problem in studies of adjuvant chemotherapy in patients with rectal cancer after preoperative (chemo)radiotherapy and surgery; less than 50% of the patients in the EORTC 22921 trial2 and CHRONICLE trial3 completed all cycles of chemotherapy. Thus, there is a possibility that survival in patients receiving adjuvant chemotherapy was no better than in patients who did not because they received inadequate courses of adjuvant chemotherapy. It is important that the authors, if possible, compare survival of patients who received the full course of adjuvant chemotherapy with that of patients who underwent observation. Furthermore, the authors could compare the survival of patients who received inadequate cycles of adjuvant chemotherapy with that of patients who underwent observation. The patients included in the metaanalysis had ypNM stage II and III disease, and the specific compliance to adjuvant chemotherapy in this subgroup was unclear. In terms of disease-free survival and distant recurrence, the authors found that adjuvant chemotherapy might benefit patients with a tumour located 10–15 cm from the anal verge. It is not clear why 5-cm intervals were chosen to separate the different parts of the rectum and how www.thelancet.com/oncology Vol 16 April 2015
the authors found that the tumours located 10–15 cm from the anal verge benefited most from adjuvant chemotherapy. We think it is possible and more reasonable to acquire the optimal cut-off value through receiver operating characteristic curves or other methods when identifying who might really benefit from adjuvant chemotherapy. It would also be interesting to do further analysis of distant metastasis incidence in different part of the rectum, and then evaluate the true value of adjuvant chemotherapy. Some retrospective studies4,5 have shown that adjuvant chemotherapy might still be valuable for patients with rectal cancer treated with preoperative (chemo)radiotherapy, although these results contradict the conclusion by Breugom and colleagues.1 The contradictory findings suggest that there might be a subgroup of patients who would benefit from adjuvant chemotherapy, and the challenge now is to define this subgroup.4 We declare no competing interests.
Kai-yun You, Zhuo-fei Bi, *Yi-min Liu, Xing-sheng Qiu [email protected] Department of Radiation Oncology, SunYat-Sen Memorial Hospital, SunYat-Sen University, Guangdong, China 1
2
3
4
Breugom AJ, Swets M, Bosset JF. Adjuvant chemotherapy after preoperative (chemo) radiotherapy and surgery for patients with rectal cancer: a systematic review and metaanalysis of individual patient data. Lancet Oncol 2015; 16: 200–07. Glynne-Jones R, Counsell N, Quirke P, et al. Chronicle: results of a randomised phase III trial in locally advanced rectal cancer after neoadjuvant chemoradiation randomising postoperative adjuvant capecitabine plus oxaliplatin (XELOX) versus control. Ann Oncol 2014; 25: 1356–62. Bosset JF, Calais G, Mineur L, et al. Fluorouracil-based adjuvant chemotherapy after preoperative chemoradiotherapy in rectal cancer: long-term results of the EORTC 22921 randomised study. Lancet Oncol 2014; 15: 184–90. Maas M, Nelemans PJ, Valentini V, et al. Adjuvant chemotherapy in rectal cancer: defining subgroups who may benefit after neoadjuvant chemoradiation and resection. A pooled analysis of 3,313 patients. Int J Cancer 2014; published online Nov 22. DOI:10.1002/ijc.29355.
5
Geva R, Itzkovich E, Shamai S,et al. Is there a role for adjuvant chemotherapy in pathological complete response rectal cancer tumors following neoadjuvant chemoradiotherapy? J Cancer Res Clin Oncol 2014; 140: 1489–94.
The meta-analysis of individual patient data by Anne Breugom and colleagues,1 addressing the benefit of adjuvant chemotherapy after neoadjuvant (chemo)radiotherapy in patients with locally advanced rectal cancer, will probably extend the controversy and debate about this topic. This meta-analysis includes only patients with pathological (y)pTNM stage II–III disease, randomised to receive adjuvant chemotherapy or undergo observation after (chemo)radiotherapy and surgery. The investigators found a benefit of adjuvant chemotherapy in diseasefree survival only in those patients with tumours located more than 10 cm from the anal verge. Our meta-analysis of retrospective studies2 suggested that the 5-year survival benefit of adjuvant chemotherapy is relevant and significant (odds ratio 0·44, p
