Textbook oncologic outcomes in elderly patients undergoing neoadjuvant chemoradiotherapy and surgery for locally advanced rectal cancer: a multicenter study

Standard treatment of locally advanced rectal cancer (LARC) involves neoadjuvant chemoradiotherapy (nCRT) followed by total mesorectal excision (TME). However, in older patients, comorbidities and frailty may limit the feasibility of this approach. This study evaluates the incidence of Textbook Oncological Outcome (TOO), a composite quality metric in surgical oncology, in patients aged ≥ 70 years undergoing low anterior resection (LAR) for LARC after nCRT and identifies predictors of achieving this benchmark. We retrospectively analyzed 157 elderly patients with LARC treated by nCRT followed by LAR between 2011 and 2023 in three Italian tertiary centers. TOO was defined as R0 resection, no prolonged hospital stays (LOS < 11 days), no major complications (Clavien-Dindo < 3b), no 30-day readmissions, and no 90-day mortality. TOO was achieved in 61% (n = 95) of patients. The most common limiting factor was prolonged LOS, met by 70.7% (n = 111), followed by the absence of 30-day readmission (87%, n = 137). The most consistently achieved components were no major complications (91%, n = 143), R0 resection (98%, n = 154), and no 90-day mortality (100%). Univariate analysis revealed that a lower (y)pTNM stage was the only significant predictor of TOO (p = 0.008), whereas age and surgical approach were not significantly associated. Survival and recurrence did not differ between patients who did and did not achieve TOO. TOO was achieved in a significant proportion of elderly patients undergoing LAR for LARC after nCRT. A multimodal approach is feasible and effective even in elderly.