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Life sciences · Journal article
BMC Cancer · October 2, 2026
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To date, standard treatment for locally advanced rectal cancer (LARC) is total neoadjuvant therapy (TNT). Neoadjuvant chemoradiotherapy (nCRT) followed by surgery is the other option. This study aimed to compare the outcomes of various preoperative treatment strategies in real-world setting. We conducted a retrospective and prospective analysis of patients with stage II–III LARC who received preoperative treatment between January 2018 and October 2023. Patients were categorized into three groups: conventional nCRT, TNT, and nCRT with perioperative chemotherapy (nCRT-POC). Pathological complete response (pCR), event-free survival (EFS), and overall survival (OS) were evaluated. Among 339 patients who completed preoperative treatment, 156 (46%) received conventional nCRT, 152 (45%) received TNT, and 31 (9%) received nCRT-POC. During preoperative treatment, 24 patients experienced disease progression, while 27 achieved a clinical complete response and underwent a watch-and-wait approach. Pathological data were available for 274 patients. The pCR rates were 11% (15/131), 24% (27/114), and 31% (9/29) in the conventional nCRT, TNT, and nCRT-POC groups, respectively. Poorly differentiated histology (OR 7.1, P = 0.018) and treatment with TNT or nCRT-POC (OR 2.37, P = 0.03) were independently associated with achieving pCR. Patients who achieved pCR had significantly better 3-year EFS (HR 0.19, P < 0.001) and OS (HR 0.12, P < 0.001). However, no significant differences in EFS or OS were observed among the three treatment strategies. Chemotherapy completion rates were significantly higher in the TNT (87%) and nCRT-POC (68%) groups than in the conventional nCRT group (57%) ( P < 0.001). In this real-world cohort, TNT was associated with higher pCR and chemotherapy completion rates than conventional nCRT, although these advantages did not translate into improved EFS or OS. While nCRT-POC also showed a higher pCR rate, this finding should be interpreted cautiously because of the small number of patients in this group. Achievement of pCR was associated with improved 3-year EFS and OS.