title: Pathologic stage is most prognostic of disease-free survival in locally advanced rectal cancer patients after preoperative chemoradiation.
abstract: BACKGROUND
  Preoperative chemoradiation is the standard treatment for locally advanced rectal cancer. However, it is uncertain whether pretreatment clinical stage, degree of response to neoadjuvant treatment, or pathologic stage is the most reliable predictor of outcome. This study compared various staging elements and treatment-related variables to identify which factors or combination of factors reliably prognosticates disease-free survival in rectal cancer patients receiving neoadjuvant combined modality therapy.
  
  
  METHODS
  From a prospectively maintained single institution database, 342 consecutive patients with locally advanced rectal cancer staged by endorectal ultrasound were identified. Patients underwent rectal resection 4 to 8 weeks after a 5.5-week course of pelvic radiotherapy/concurrent chemotherapy. The degree of tumor regression was histologically graded on each resected specimen using a previously reported response scale of 0% to 100%. Predictive models of disease-free survival were created utilizing available pretherapy and postoperative staging elements in addition to the degree of tumor regression noted histologically. Model accuracy was measured and compared by concordance index, with 95% confidence interval (CI).
  
  
  RESULTS
  Stratifying patients by degree of tumor regression predicted outcome with a concordance index of 0.65 (95% CI, 0.59-0.71), which was significantly better than models using preoperative stage elements (concordance index of 0.54; 95% CI, 0.50-0.58). However, the model found to be most predictive of disease-free survival stratified patients by final pathologic T classification and N classification elements, with a concordance index of 0.75 (95% CI, 0.70-0.80).
  
  
  CONCLUSIONS
  Tumor response to preoperative therapy is a strong predictor of disease-free survival. However, outcome is most accurately estimated by final pathologic stage, which is influenced by both preoperative stage and response to therapy.
authors.affiliation: Department of Colorectal Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
authors.forename: Hak-Mien
authors.initials: HM
authors.lastname: Quah
authors.forename: Joanne F
authors.initials: JF
authors.lastname: Chou
authors.forename: Mithat
authors.initials: M
authors.lastname: Gonen
authors.forename: Jinru
authors.initials: J
authors.lastname: Shia
authors.forename: Deborah
authors.initials: D
authors.lastname: Schrag
authors.forename: Leonard B
authors.initials: LB
authors.lastname: Saltz
authors.forename: Karyn A
authors.initials: KA
authors.lastname: Goodman
authors.forename: Bruce D
authors.initials: BD
authors.lastname: Minsky
authors.forename: W Douglas
authors.initials: WD
authors.lastname: Wong
authors.forename: Martin R
authors.initials: MR
authors.lastname: Weiser
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017024:Chemotherapy, Adjuvant; D003131:Combined Modality Therapy; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging; D011379:Prognosis; D018714:Radiotherapy, Adjuvant; D012004:Rectal Neoplasms / Q000473:pathology* / Q000628:therapy; D016896:Treatment Outcome