NORAD01-GRECCAR16 multicenter phase III non-inferiority randomized trial comparing preoperative modified FOLFIRINOX without irradiation to radiochemotherapy for resectable locally advanced rectal cancer (intergroup FRENCH-GRECCAR- PRODIGE trial)

Abstract

Background Preoperative radiochemotherapy (RCT) is recommended in France prior to total mesorectal excision in patients with mid or low locally advanced rectal cancer (LARC) (cT3/T4 and/or N+) because it has been shown to improve local control. Preoperative RCT has also disadvantages including the absence of proven impact on metastatic recurrence and the risk of late side effects on bowel and genitourinary function. In patients with primarily resectable LARC, preoperative systemic chemotherapy without pelvic irradiation could be used as an alternative to RCT. Methods This study is a multicenter, open-label randomized, 2-arm phase III non-inferiority trial. Patients with mid or low resectable LARC (cT3N0 or cT1-T3N+ with circumferential resection margin [CRM] > 2 mm on pretreatment MRI) will be randomized to either modified FOLFIRINOX for 3 months or RCT (Cap50 intensified-modulated radiotherapy). All patients have restaging MRI after preoperative treatment. The primary endpoint is 3-year progression-free survival (PFS) from the time to randomization including progression during preoperative treatment. Secondary endpoints are treatment related toxicity, treatment compliance, R0 resection rate, sphincter saving surgery rate, postoperative morbidity and mortality rates, loco-regional recurrence free survival, overall survival, bowel and sexual functions at diagnosis, quality of life, radiologic and pathologic response after preoperative treatment. The number of patients required is 574. Discussion The choice of modified FOLFIRINOX for preoperative chemotherapy is supported by recent and consistent data on safety and efficacy of this regimen on rectal cancer. The use of preoperative chemotherapy instead of RCT could be associated with pronounced advantages in terms of functional results and quality of life in cancer survivors. However and first of all, the non-inferiority of preoperative chemotherapy compared to RCT on oncologic outcome has to be validated. If this study demonstrates the non-inferiority of chemotherapy compared to RCT, this can lead to a crucial change in clinical practice in a large subset of rectal cancer patients. Trial registration ClinicalTrials.gov NCT03875781 (March 15, 2019). Version 1.1.

Total neoadjuvant therapy for rectal cancer: Making sense of the results from the RAPIDO and PRODIGE 23 trials

“…Assuming that this notion holds true for early-stage patients, the advantage of administrating mFOLFIRINOX upfront lies in the rapid and deep tumour downsizing, thus improving tumour-related symptoms and widening the proportion of patients who could potentially be spared from sequential radiotherapy within the context of an adaptive treatment strategy [51]. Of note, the potential of mFOLFIR-INOX in this setting is being addressed in the ongoing NORAD01 trial [64]. As far as the risk of increased toxicity is concerned, data from the PRODIGE 23 trial appear reassuring overall, and they suggest that safety is less of an issue in this setting, this conclusion being likely influenced by the early-stage population.…”

The “Immunoscore” in rectal cancer: could we search quality beyond quantity of life?

“…In the NORAD01-GRECCAR16 multicenter phase III trial of patients with primarily resectable LARC, preoperative systemic chemotherapy without pelvic irradiation is tested as an alternative to CRT [ 45 ]. The choice of modified FOLFIRINOX for preoperative chemotherapy is supported by the recent and consistent data on the safety and efficacy of this regimen from large phase III trial of patients with LARC [ 46 ].…”

TNT: Raising more questions than answers?

“…18 The final report showed similar DFS, OS, R0 resection, and local recurrence rates in all arms, despite less tumor regression with the non-CRT arm, but greatly improved anal func-tion without CRT. Other RCTs trials addressing this question include NORAD01-GRECCAR 16 (n = 574), which compares induction OX-FP-irinotecan chemotherapy to intensified CRT, prior to surgery, 19 and PROSPECT (n = 1194), which asks whether CRT can be safely omitted in good responders to induction chemotherapy, compared to standard treatment. 20 What about improving outcomes for poor responders to neoadjuvant treatment?…”