Short Course or Long Course Radiotherapy as Total Neoadjuvant Therapy in Locally Advanced Rectal Cancer

The SHOOL study is a single-institution, open-label, randomized prospective study designed to evaluate and compare two internationally accepted total neoadjuvant therapy (TNT) strategies in patients with locally advanced rectal cancer (LARC). These strategies differ primarily in their radiotherapy schedule and include:

Arm A: Short-course radiotherapy (SCRT; 25 Gy in 5 fractions over 1 week), followed by consolidation chemotherapy and surgery

Arm B: Long-course chemoradiotherapy (LCRT; 50.4 Gy in 28 fractions with concurrent Capecitabine over 5-5.5 weeks), followed by consolidation chemotherapy and surgery The study acronym "SHOOL" reflects the clinical dilemma of whether SHOrt-course Or Long-course radiotherapy offers better or more practical outcomes when delivered within a TNT framework.

This prospective study aims to explore how these two strategies compare in terms of tumour response (as measured by pathological complete response, pCR), toxicity, treatment compliance, feasibility, quality of life, and local recurrence rates at 3 and 5 years. Given that both arms represent evolving standards of care, this study is designed to generate real-world data that can guide institutional decision-making and inform future definitive trials.

Inclusion criteria

• Histologically confirmed adenocarcinoma of the rectum
• Locally advanced disease based on MRI including cT3-T4 and/or node positive disease (cN1 or N2)
• Tumor located within 15 cm from the anal verge (confirmed by endoscopy or MRI)
• ECOG performance status 0-2
• Hemoglobin ≥ 9 g/dL
• Absolute neutrophil count ≥ 1,500/mm³
• Platelets ≥ 100,000/mm³
• Total bilirubin ≤ 1.5 × ULN
• Aspartate transaminase/Alanine transaminase ≤ 2.5 × ULN
• Serum creatinine ≤ 1.5 × ULN or creatinine clearance ≥ 60 mL/min
• Fit for neoadjuvant therapy and curative resection
• Willing and able to provide written, informed consent
• Baseline MRI and biopsy (even if done outside) must be reviewed and approved by the institutional radiology and pathology review board, requiring concurrence from two independent pathologists and two independent radiologists

Exclusion criteria

• Metastatic disease at presentation (distant nodes, liver, lung, peritoneum, etc.)
• Prior pelvic radiotherapy or systemic chemotherapy for rectal cancer
• Presence of synchronous malignancies or previous malignancy within 5 years except: Treated basal cell or squamous cell carcinoma of the skin, In situ cervical cancer, Active uncontrolled infection
• Known HIV infection with CD4 < 200 cells/μL, or active hepatitis B or C
• Severe comorbid conditions precluding therapy (e.g., decompensated cardiac, hepatic, or renal disease)
• Pregnant or breastfeeding women
• Inability to comply with protocol requirements or follow-up schedule
• Psychiatric illness or social situations that may limit compliance with study requirements