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      Nomogram for predicting disease-free survival among a multicenter cohort of Chinese patients with locally advanced rectal cancer

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          Abstract

          Purpose: This study aimed to develop and validate a nomogram for predicting 3-year disease-free survival (DFS) among a multicenter cohort of Chinese patients with locally advanced rectal cancer (LARC) who underwent preoperative therapy followed by surgery. This nomogram might help identify patients who would benefit from postoperative adjuvant chemotherapy and close follow-up.

          Materials and methods: All data from 228 patients in two independent Chinese cohorts (118 patients and 110 patients) were pooled and subjected to survival analysis. One cohort’s data were used to develop multivariate nomograms based on Cox regression, and the second cohort was used for external validation. The variables were sex, age, clinical tumor stage, tumor location, preoperative therapy protocol, adjuvant chemotherapy, surgical procedure, surgical approach, pTNM stage, tumor deposit, tumor regression grade, lymphovascular invasion, perineural invasion, pretreatment serum carcinoembryonic antigen (CEA) level, preoperative CEA level, and postoperative CEA level. The model’s performance was evaluated based on its discrimination, calibration, and clinical usefulness.

          Results: The nomogram was based on ypT stage and ypN stage, and the C-index values for 3-year DFS were 0.70 in the training cohort (95% confidence interval: 0.62–0.78) and 0.78 in the validation cohort (95% confidence interval: 0.68–0.89). The Hosmer-Lemeshow calibration test revealed good calibration for predicting 3-year DFS in the training and validation cohorts, and decision curve analysis demonstrated that the nomogram was clinically useful.

          Conclusion: This nomogram including the ypT stage and ypN stage could predict DFS at 3 years after surgery, which may help better identify Chinese patients who would benefit from additional postoperative adjuvant systemic treatment.

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          Most cited references17

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          How to build and interpret a nomogram for cancer prognosis.

          Nomograms are widely used for cancer prognosis, primarily because of their ability to reduce statistical predictive models into a single numerical estimate of the probability of an event, such as death or recurrence, that is tailored to the profile of an individual patient. User-friendly graphical interfaces for generating these estimates facilitate the use of nomograms during clinical encounters to inform clinical decision making. However, the statistical underpinnings of these models require careful scrutiny, and the degree of uncertainty surrounding the point estimates requires attention. This guide provides a nonstatistical audience with a methodological approach for building, interpreting, and using nomograms to estimate cancer prognosis or other health outcomes.
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            Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial

            Summary Background Preoperative or postoperative radiotherapy reduces the risk of local recurrence in patients with operable rectal cancer. However, improvements in surgery and histopathological assessment mean that the role of radiotherapy needs to be reassessed. We compared short-course preoperative radiotherapy versus initial surgery with selective postoperative chemoradiotherapy. Methods We undertook a randomised trial in 80 centres in four countries. 1350 patients with operable adenocarcinoma of the rectum were randomly assigned, by a minimisation procedure, to short-course preoperative radiotherapy (25 Gy in five fractions; n=674) or to initial surgery with selective postoperative chemoradiotherapy (45 Gy in 25 fractions with concurrent 5-fluorouracil) restricted to patients with involvement of the circumferential resection margin (n=676). The primary outcome measure was local recurrence. Analysis was by intention to treat. This study is registered, number ISRCTN 28785842. Findings At the time of analysis, which included all participants, 330 patients had died (157 preoperative radiotherapy group vs 173 selective postoperative chemoradiotherapy), and median follow-up of surviving patients was 4 years. 99 patients had developed local recurrence (27 preoperative radiotherapy vs 72 selective postoperative chemoradiotherapy). We noted a reduction of 61% in the relative risk of local recurrence for patients receiving preoperative radiotherapy (hazard ratio [HR] 0·39, 95% CI 0·27–0·58, p<0·0001), and an absolute difference at 3 years of 6·2% (95% CI 5·3–7·1) (4·4% preoperative radiotherapy vs 10·6% selective postoperative chemoradiotherapy). We recorded a relative improvement in disease-free survival of 24% for patients receiving preoperative radiotherapy (HR 0·76, 95% CI 0·62–0·94, p=0·013), and an absolute difference at 3 years of 6·0% (95% CI 5·3–6·8) (77·5% vs 71·5%). Overall survival did not differ between the groups (HR 0·91, 95% CI 0·73–1·13, p=0·40). Interpretation Taken with results from other randomised trials, our findings provide convincing and consistent evidence that short-course preoperative radiotherapy is an effective treatment for patients with operable rectal cancer. Funding Medical Research Council (UK) and the National Cancer Institute of Canada.
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              Decision curve analysis.

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                Author and article information

                Journal
                Cancer Manag Res
                Cancer Manag Res
                CMAR
                cancmanres
                Cancer Management and Research
                Dove
                1179-1322
                29 March 2019
                2019
                : 11
                : 2471-2483
                Affiliations
                [1 ]Department of Radiology, The Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer Hospital , Kunming 650118, People’s Republic of China
                [2 ]Department of Radiology, The Sixth Affiliated Hospital of Sun Yat-sen University , Guangzhou 510655, People’s Republic of China
                [3 ]Department of Radiology, Guangdong General Hospital, Guangdong Academy of Medical Sciences , Guangzhou 510080, People’s Republic of China
                [4 ]School of Medicine, South China University of Technology , Guangzhou 510641, People’s Republic of China
                [5 ]Department of Pathology, The Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer Hospital , Kunming 650118, People’s Republic of China
                [6 ]Department of Colorectal Surgery, The Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer Hospital , Kunming 650118, People’s Republic of China
                [7 ]Department of Medical Oncology, The Sixth Affiliated Hospital of Sun Yat-sen University , Guangzhou 510655, People’s Republic of China
                Author notes
                Correspondence: Jian DongDepartment of Colorectal Surgery, The Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer Hospital , No. 519 Kunzhou Road, Xishan District, Kunming650118, People’s Republic of ChinaTel +86-871-68179549Fax +86-871-68181942 Email 3196259175@ 123456qq.com
                Jian XiaoDepartment of Medical Oncology, The Sixth Affiliated Hospital of Sun Yat-sen University , No. 26 Yuancunerheng Road, Tianhe District, Guangzhou510655, People’s Republic of ChinaTel +86-20-38250745Fax +86-20-38250745 Email xiao_jian@ 123456139.com
                [*]

                These authors contributed equally to this work

                Article
                196614
                10.2147/CMAR.S196614
                6497859
                31114319
                8a012651-669d-47e1-a295-8b8b74615d3d
                © 2019 Li et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                History
                : 30 November 2018
                : 01 March 2019
                Page count
                Figures: 4, Tables: 2, References: 27, Pages: 13
                Categories
                Original Research

                Oncology & Radiotherapy
                rectal cancer,disease-free survival,recurrence,nomogram
                Oncology & Radiotherapy
                rectal cancer, disease-free survival, recurrence, nomogram

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