What is the prognosis for rectal cancer?

From the Guidelines

The prognosis for rectal cancer is significantly influenced by the stage at diagnosis, with a 5-year survival rate ranging from over 90% for stage I to about 15% for stage IV disease, as reported in recent guidelines 1.

Key Factors Influencing Prognosis

The prognosis for rectal cancer depends on several key factors, including:

• Tumor depth
• Lymph node involvement
• Distant metastasis
• Tumor grade
• Molecular characteristics like microsatellite instability status Treatment approaches vary based on the stage and these factors, with a multidisciplinary approach often combining surgery, radiation, and chemotherapy.

Treatment Approaches

For early-stage disease, surgery alone may be sufficient, while locally advanced rectal cancer often requires neoadjuvant chemoradiation followed by total mesorectal excision surgery, as outlined in the ASCO guideline 1. Metastatic disease is treated with systemic chemotherapy regimens such as FOLFOX or FOLFIRI, sometimes with targeted agents like bevacizumab or cetuximab depending on molecular testing. The NCCN Guidelines Insights also detail recent updates, including the addition of endoscopic submucosal dissection as an option for early-stage rectal cancer and updates to the total neoadjuvant therapy approach 1.

Follow-Up and Lifestyle Modifications

Regular follow-up is essential after treatment, including physical exams, CEA blood tests, colonoscopy, and imaging studies to monitor for recurrence. Newer approaches like total neoadjuvant therapy and watch-and-wait protocols for complete clinical responders are improving outcomes for selected patients, as discussed in the context of recent clinical trials 1. Lifestyle modifications, including regular exercise and a healthy diet, may also positively impact long-term survival. A multidisciplinary approach and careful patient selection are crucial for balancing curative-intent therapy with minimal impact on quality of life, especially for patients with distal rectal cancer 1.

From the FDA Drug Label

The median age was 60 years; 60% were male, 79% were White, 57% had an ECOG performance status of 0,21% had a rectal primary and 28% received prior adjuvant chemotherapy. The addition of bevacizumab improved survival across subgroups defined by age (<65 years, ≥65 years) and sex. Among the 110 patients randomized to bevacizumab with fluorouracil and leucovorin, median OS was 18.3 months, median progression-free survival (PFS) was 8.8 months, overall response rate (ORR) was 39%, and median duration of response was 8. 5 months.

Rectal Cancer Prognosis:

• The prognosis for rectal cancer patients treated with bevacizumab is associated with improved overall survival, with a median OS of 20.3 months in patients with metastatic colorectal cancer, including those with rectal primary.
• The addition of bevacizumab to chemotherapy resulted in significantly longer survival and higher overall response rates.
• However, the prognosis may vary depending on individual patient factors, such as age, sex, and prior treatment history. 2

From the Research

Rectal Cancer Prognosis

• The prognosis for rectal cancer patients has been studied in various clinical trials and research studies 3, 4, 5, 6, 7.
• A study published in 2017 found that a high operating volume, a specialized surgeon in colorectal surgery, a total mesorectal excision, and an adjuvant chemotherapy given within no more than 8 weeks following the curative resection can improve prognosis in rectal cancer with level I of evidence 5.
• The same study found that anastomotic leak and diabetes can worsen prognosis in rectal cancer with level I of evidence 5.
• A phase III randomized clinical trial published in 2015 found that capecitabine can be substituted for continuous infusion 5-FU in the curative setting of stage II/III rectal cancer during neoadjuvant radiation therapy, with similar outcomes for local-regional control, disease-free survival, and overall survival 6.
• The addition of oxaliplatin to capecitabine-based neoadjuvant chemoradiotherapy did not improve local-regional failure rate, disease-free survival, or overall survival, but did add considerable toxicity 6.
• A retrospective study published in 2023 found that capecitabine-based neoadjuvant chemoradiotherapy provides high rates of survival and sphincter preservation with acceptable toxicity, and that ypTNM stage was significantly associated with disease-free survival, while positive mesorectal fasciae status on magnetic resonance imaging and ypTNM stage were significantly related to overall survival 7.

Prognostic Factors

• The main prognostic factors found in literature that surgeons can act on include:
  • Neoadjuvant treatment
  • High operating volume of the surgeon
  • High tie of the inferior mesenteric artery
  • Mesorectal excision
  • RO resection
  • Improvement of the techniques of intersphincteric resection and techniques of anastomosis
  • Adjuvant chemotherapy within less than 8 weeks when appropriate 5
• Other prognostic factors include:
  • ypTNM stage
  • Positive mesorectal fasciae status on magnetic resonance imaging
  • Distant metastasis 7

Treatment Outcomes

• The overall 5-year survival rate for rectal cancer patients is around 53% for all stages 5.
• A study published in 2023 found that the 3-year disease-free survival and 3-year overall survival rates for patients treated with capecitabine-based neoadjuvant chemoradiotherapy were 74.4% and 83.2%, respectively 7.
• The pathological complete response rate for patients treated with capecitabine-based neoadjuvant chemoradiotherapy was 19.8% 7.