Early Outcomes of Total Neoadjuvant Therapy Using the RAPIDO Protocol in Locally Advanced Rectal Cancer: Experience from a Malaysian Colorectal Centre

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Abstract Background: Locally advanced rectal cancer (LARC) is commonly treated with long-course chemoradiotherapy followed by total mesorectal excision and adjuvant chemotherapy; however, systemic recurrence remains a major challenge. The RAPIDO trial introduced total neoadjuvant therapy using short-course radiotherapy followed by systemic chemotherapy, demonstrating improved pathological complete response (pCR) rates and reduced treatment failure. Objectives: To evaluate the feasibility, treatment adherence, and outcomes of the RAPIDO protocol for LARC in a Malaysian tertiary centre. Design: Retrospective cohort study. Settings: Hospital Sultanah Aminah, Johor Bahru. Patients (Materials) and Methods: Patients with clinical stage II–III LARC who underwent the RAPIDO protocol between January 2021 and June 2023 were included, and their clinical characteristics, treatment adherence, surgical outcomes, and survival were analyzed. Main Outcome Measures: Chemotherapy completion, pCR rate, R0 resection rate, and overall survival (OS). Sample Size: Forty patients. Results: Eighteen patients (45%) proceeded to surgery, while 22 (55%) did not. Chemotherapy completion was significantly associated with improved 12-month survival. The surgical cohort achieved an R0 resection rate of 83.3% and a pCR rate of 16.7%. Mean OS was longer in the surgical group (11.8 months) than the nonsurgical group (9.7 months). Kaplan–Meier analysis showed significantly better survival among patients who underwent surgery (log-rank P = .021) and those who completed chemotherapy (log-rank P = .016). Conclusions: The RAPIDO protocol was feasible in this Southeast Asian setting, with adherence—particularly chemotherapy completion—emerging as a key determinant of survival. Limitations: Retrospective design, small sample size, and high attrition may have introduced selection bias and limited statistical power. Conflict of interest: None.

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