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Life sciences · Journal article
Reports of Practical Oncology & Radiotherapy · September 23, 2026
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Background: Improved control of distant metastases has made total neoadjuvant therapy (TNT) a standard of care for locally advanced rectal cancer (LARC). However, its toxicity raises concerns about overtreatment in lower-risk populations. This study evaluates long-term outcomes of capecitabine-based neoadjuvant chemoradiotherapy (Cap-CRT) and proposes a pre-treatment clinical risk stratification for distant metastasis and survival. Materials and methods: A single-centre retrospective analysis of 207 consecutive patients treated with Cap-CRT (45 Gy plus capecitabine 825 mg/m 2 twice daily) between 2008 and 2018. Total mesorectal excision (TME) was performed 6–8 weeks after completion of Cap-CRT. The Kaplan–Meier method and log-rank test, as well as the Cox regression model for multivariable analysis, were utilised. Results: After a median follow-up of 48 months, the 5-year overall survival (OS), 5-year disease-free survival (DFS), 5-year local relapse-free survival (LRFS), 5-year nodal relapse-free survival (NRFS), and 5-year distant metastasis-free survival (DMFS) rates were 87%, 75%, 94%, 95%, and 82%, respectively. The operability rate was 92%, with an 82.7% sphincter preservation rate. A pathological complete response (pCR) occurred in 16.2% of patients. Multivariable analysis showed that a lack of downstaging, positive margins and ypN2 stage independently predicted worse OS. Worse DMFS was associated with a lack of downstaging, positive margins and radiological sphincter involvement (RSI). To assist in pre-treatment decision-making, a low-risk group (cT2N1 or cT3N0) was defined, with an excellent prognosis compared with that of patients with cT3N1–2 or cT4N0–2 stages in terms of 5-year OS (100% vs. 80%; HR = 0.075, 95% CI: 0.01–0.558, p < 0.001) and 5-year DMFS (93% vs. 84%; HR = 0.319, 95% CI: 0.123–0.827, p = 0.013). The rate of grade 3 toxicity was only 5.3%. Conclusions: For low-risk patients (cT2N1/cT3N0), neoadjuvant Cap-CRT remains a satisfactory alternative, achieving excellent oncological outcomes with low toxicity in LARC.