# Improved survival with preoperative radiotherapy in resectable rectal cancer (Swedish Rectal Cancer Trial)

Source: https://onco.cc/key-papers/paper-swedish-rectal-cancer-trial-preoperative-radiotherapy-nejm-1997/  
OnCo record `paper-swedish-rectal-cancer-trial-preoperative-radiotherapy-nejm-1997` (Key paper). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Five days of radiotherapy before the operation more than halved the chance of the cancer coming back in the pelvis, and was the first rectal cancer trial to show that radiotherapy also helps people live longer.

## Summary

Between March 1987 and February 1990 the Swedish Rectal Cancer Trial randomly assigned 1,168 patients younger than 80 with resectable rectal cancer to preoperative irradiation (25 Gy in five fractions in one week) followed by surgery within one week, or to surgery alone. Irradiation did not increase postoperative mortality.

The difference in local recurrence was found in all subgroups defined by Dukes' stage. The trial predates total mesorectal excision as a standard, which is why the Dutch TME trial had to ask the question again against better surgery.

## Fields

- Kind: Key paper
- Last checked: 2026-09-24
- Tags: colorectal-evidence
- Journal: New England Journal of Medicine
- Year: 1997
- DOI: 10.1056/NEJM199704033361402
- Authors: Swedish Rectal Cancer Trial, Cedermark B, Dahlberg M, et al.
- Findings: Local recurrence at five years 11 percent (63 of 553) with preoperative radiotherapy against 27 percent (150 of 557) with surgery alone, p<0.001.; Overall five-year survival 58 percent against 48 percent, p=0.004.; Cancer-specific survival at nine years after curative resection 74 percent against 65 percent, p=0.002.; Irradiation did not increase postoperative mortality.
- What it means: The origin of short-course preoperative radiotherapy, still the standard schedule across northern Europe and the backbone of the RAPIDO regimen 24 years later.
- Caveats: Surgery was not standardised as total mesorectal excision; the 27 percent local recurrence in the control arm is far above modern rates, which inflates the absolute benefit.; The survival benefit has not been reproduced in trials with modern surgery.; Long-term bowel and sexual dysfunction after pelvic radiotherapy were not the focus of the original report.

## Sources

- N Engl J Med 1997: https://doi.org/10.1056/NEJM199704033361402
- PubMed: https://pubmed.ncbi.nlm.nih.gov/9091798/

## Connected records

- roadmaps: [Colorectal cancer roadmap: from the adenoma-carcinoma sequence and the first screening trials to total mesorectal excision, oxaliplatin, RAS testing, immunotherapy for mismatch repair-deficient disease, ctDNA-guided treatment and organ preservation](https://onco.cc/roadmaps/colorectal-roadmap/), [Radiotherapy roadmap: X-rays → shaped beams → fewer fractions, particles and FLASH](https://onco.cc/roadmaps/radiation-roadmap/)
- key papers: [Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer (Dutch TME trial)](https://onco.cc/key-papers/paper-kapiteijn-dutch-tme-preoperative-radiotherapy-nejm-2001/)
- cancers: [Colorectal cancer](https://onco.cc/cancers/colorectal/), [Rectal cancer](https://onco.cc/cancers/rectal-cancer/)
- fronts: [Radiation Therapy](https://onco.cc/fronts/radiation/), [Surgery & Interventional](https://onco.cc/fronts/surgery/)
- terms: [Neoadjuvant / adjuvant / perioperative](https://onco.cc/terms/neoadjuvant-adjuvant/), [Radiotherapy](https://onco.cc/terms/radiotherapy/), [Total mesorectal excision (TME)](https://onco.cc/terms/total-mesorectal-excision/)
- technologies: [IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/)
- institutions: [Karolinska University Hospital](https://onco.cc/institutions/karolinska/)
- bottlenecks: [Surgery and radiotherapy cure most, get least](https://onco.cc/bottlenecks/b-surgery-radiation-innovation/), [Toxicity and quality of life are undervalued](https://onco.cc/bottlenecks/b-toxicity-qol/)
- journals: [New England Journal of Medicine](https://onco.cc/journals/nejm/)

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