The quality of evidence is downgraded by indirectness.
A Cochrane review [Abstract] 1 included 21 studies with a total of 9 785 patients with rectal carcinoma, comparing adjuvant chemotherapy after radical surgery to surgery only.
The meta-analysis showed a significant reduction in the risk of death (17%) among patients undergoing postoperative chemotherapy as compared to those undergoing observation (HR=0.83, 95% CI 0.76 to 0.91). Between-study heterogeneity was moderate (I2 30%, P=0.09).
Disease-free survival (DFS) data were reported in 20 RCTs, and the data suitable for meta-analysis included 8 530 patients. Of these, 4 515 patients were randomized to postoperative chemotherapy (treatment arm) and 4 015 patients received no postoperative chemotherapy (control arm). The meta-analysis of these RCTs showed a reduction in the risk of disease recurrence (25%) among patients undergoing adjuvant chemotherapy as compared to those undergoing observation (HR0.75, 95% CI 0.68 to 0.83). Between-study heterogeneity was moderate (I2 41%, P=0.03). In patients receiving preoperative radiotherapy, adding chemotherapy preoperatively or postoperatively had no significant effect on survival, and chemotherapy, regardless of whether it was administered before or after surgery, conferred a significant benefit only with respect to local disease control.
Available data were insufficient to investigate on the effect of adjuvant chemotherapy separately in different TNM stages in terms of both OS and DFS.
Precise anatomical excision of the rectum and its mesentery, e.g. total mesorectal excision (TME) is essential and has led to improvements in local recurrence rate and long-term outcomes. Preoperative neoadjuvant radiation or chemoradiation is widely used.
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