Impact of T and N substage on survival and disease relapse in adjuvant rectal cancer: a pooled analysis.
OBJECTIVE
To determine the rates of survival and disease control by TNM and MAC stage in three randomized North American rectal adjuvant studies.


METHODS
Data were merged from 2551 eligible patients on NCCTG 79-47-51 (n = 200), NCCTG 86-47-51 (n = 656), and INT 114 (n = 1695). All patients received postoperative radiation, and 96% were randomized to receive concomitant and maintenance chemotherapy. Five-year follow-up was available in 94% of patients and 7-yr follow-up in 84%. Kaplan-Meier curves were used to estimate the distribution of overall survival (OS) and disease-free survival (DFS), and p values were derived using the log-rank test. Time to local and distant relapse was estimated using cumulative incidence methodology. Analyses were adjusted for treatment effect using Cox proportional hazards models.


RESULTS
OS and DFS were dependent on both TN stage and NT stage (N substage within T stage and T substage within N stage). Even among N2 patients (4 or more LN+), T stage influenced 5-yr OS (T1-2, 69%; T3, 48%; T4, 38%). Three risk groups of patients were defined: (1) intermediate: T3N0, T1-2N1; (2) moderately high: T4N0, T1-2N2, T3N1; and (3) high: T3N2, T4N1, T4N2. For Group 1, 5-yr OS was 74% and 81%, and 5-yr DFS was 66% and 74%. For Group 2, 5-yr OS ranged from 61% to 69%, and for Group 3, OS ranged from 33% to 48%. Cumulative incidence rates of local relapse and distant metastases revealed similar differences by TN and NT stage, as seen in the survival analyses.


CONCLUSIONS
Patients with a single high-risk factor of either extension beyond the rectal wall (T3N0) or nodal involvement (T1-2N1) have improved OS, DFS, and disease control when compared to those with both high risk factors. Different treatment strategies may be indicated for intermediate- (T3N0, T1-2N1) vs. moderately high or high-risk patients in view of differential survival and rates of relapse. For future trial design, it may be preferable to perform separate studies, or a planned statistical analysis, for the "intermediate-risk" vs. the "moderately high" or "high-risk" subsets of patients.
Gunderson
Leonard L
LL
Department of Radiation Oncology, Mayo Clinic Scottsdale, Scottsdale, AZ 85259, USA.
Sargent
Daniel J
DJ
Tepper
Joel E
JE
O'Connell
Michael J
MJ
Allmer
Cristine
C
Smalley
Steven R
SR
Martenson
James A
JA
Haller
Daniel G
DG
Mayer
Robert J
RJ
Rich
Tyvin A
TA
Ajani
Jaffer A
JA
Macdonald
John S
JS
Goldberg
Richard M
RM
D017024:Chemotherapy, Adjuvant; D005500:Follow-Up Studies; D006801:Humans; D009367:Neoplasm Staging; D012004:Rectal Neoplasms / Q000188:drug therapy / Q000401:mortality* / Q000473:pathology* / Q000532:radiotherapy; D012008:Recurrence; D013223:Statistics as Topic; D015996:Survival Rate; D013997:Time Factors