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Evaluating the influence of the obesity paradox on survival outcomes in patients being treated surgically for rectal cancer—a systematic review and meta-analysis

Matthew G. Davey,N. Donlon,M. Donnelly,Éanna J. Ryan,O. Ryan,Ian Reynolds,William P Joyce

Published 2025 in International Journal of Colorectal Disease

ABSTRACT

Obesity is a well-established risk factor for rectal cancer development. The association between obesity and survival outcomes in those undergoing resection for rectal cancer remains unclear. The objective of this study was to perform a systematic review and meta-analysis evaluating the association between obesity and overall (OS) and disease-free (DFS) in patients undergoing surgery for rectal cancer with curative intent. A systematic review was performed as per PRISMA guidelines. Descriptive statistics (Fisher’s exact test (†)) were used. Meta-analyses were performed using Mantel–Haenszel and generic inverse variance methods using RevMan version 5.4. Twenty-three studies with 22,520 patients were included (mean follow-up: 59.7 months). Overall, 18.5% of patients were living with obesity (4174/22,520). Obesity was associated with poorer DFS [60.5% (2289/3783) vs. 62.4% (9576/15,335), P = 0.029, †]; however, a non-significant difference was observed at meta-analysis [hazard ratio (HR): 1.12, 95% confidence interval (95% CI) 0.90–1.40, P = 0.320, heterogeneity (I2) = 77%]. Obesity was associated with enhanced OS [67.8% (2500/3687) vs. 59.8% (9048/15,125), P < 0.001, †], results which were replicated at meta-analysis [HR 1.24, 95% CI 1.03–1.50, P = 0.020, I2 = 59%]. Using time-to-effect modelling, a non-significant difference in DFS [HR 0.93, 95% CI 0.69–1.24, P = 0.600, I2 = 57%] and OS [HR 1.00, 95% CI 0.73–1.37, P = 1.000, I2 = 69%] was observed at meta-analysis. Once diagnosed and being treated with curative intent for rectal cancer, patients living with obesity exhibit similar survival outcomes as those living without obesity. This study refutes hypotheses that an ‘obesity paradox’ is protective for survival in patients with rectal cancer. Given the current obesity epidemic, this concept may warrant incorporation into preoperative counselling.

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