Evolution of Prognosis and Management in Curative Treatment of Locally Recurrent Rectal Cancer: A Comprehensive Analysis from 2000 to 2023

BACKGROUND: Despite advances in diagnosis and treatment, locally recurrent rectal cancer (LRRC) remains a complex condition associated with a poor prognosis. This study aimed to evaluate long-term trends in the management of and oncological outcomes for patients with LRRC treated in a Dutch tertiary referral center. METHODS: All consecutive patients with a confirmed diagnosis of a first LRRC undergoing curative-intent surgical resection at our referral center between 2000 and 2023 were retrospectively analyzed. Primary outcomes were trends in overall survival (OS), disease-free survival (DFS), clear (R0) resection rate, and postoperative complication rates. Cumulative sum (CUSUM) analysis was used to visualize changes in these outcomes over time. Secondary endpoints included temporal changes in prognostic factors associated with improved OS and DFS. RESULTS: A total of 560 patients undergoing curative-intent surgical resection were included. Over time, patients presented with more comorbidities (p < 0.001), more multifocal disease (p < 0.001), and synchronous metastasis (p < 0.001). The R0 resection rate improved from 59% to 78% over the study period (p < 0.001). CUSUM analyses demonstrated an upward trend in OS and DFS, indicating a cumulative improvement in survival relative to the reference survival probability. In univariable Cox regression, the most recent time period (2018-2023) was significantly associated with improved OS (hazard ratio 0.75; 95% confidence interval 0.58-0.97; p = 0.030). CONCLUSIONS: Over the past two decades, the outcomes of patients undergoing curative-intent treatment for LRRC have steadily improved. This may reflect advances in diagnostics, neoadjuvant therapy, surgical technique and perioperative care, centralization of care, and patient selection.