The multidisciplinary management of locally advanced rectal cancer

ABSTRACT

Introduction

The classic paradigm for the management of locally advanced rectal cancer (LARC) consists of (chemo)radiotherapy (C)RT), total mesorectal excision, and adjuvant chemotherapy (CHT). At present, due to the high rate of distant metastasis (up to 30%), the total neoadjuvant therapy (TNT) with the administration of systemic CHT in the neoadjuvant setting has gained acceptance as standard of care.

Our aim is to critically review the current literature on LARC management and summarize the different approaches recently proposed to improve clinical outcomes. It represents a starting step to develop an effective strategy that ultimately could harmonize the standard of care in daily clinical practice.

Areas covered

Studies reporting the impact of TNT approaches were deemed eligible. De-escalation strategies, including non-operative management (NOM) after TNT, as well as RT omission or systemic therapy alone, were also investigated.

Expert opinion

The year 2020 has seen promising new data from randomized phase III trials in the field of LARC management. Nowadays, TNT strategy has been accepted as the primary treatment for LARC. The role of de-escalation strategies is still unknown. The goal is to achieve better survival outcomes with improving quality of life. Only selected patients are likely to benefit from NOM or immunotherapy alone.

KEYWORDS:

• Rectal cancer
• radiotherapy
• chemotherapy
• immunotherapy
• total neoadjuvant therapy
• non operative management
• survival
• local control

Article highlights

• Total neoadjuvant therapy (TNT) involves both systemic therapy and (chemo)radiotherapy prior to surgery.

• TNT has emerged as a novel therapeutic strategy in the management of locally advanced rectal cancer (LARC).

• A non-operative management (NOM) after TNT can be considered as a potential treatment option for selected LARC patients.

• Omission of neoadjuvant RT may be feasible in those LARC patients considered at low risk for locoregional recurrence.

• Immunotherapy alone has proven successful in treating MMR-deficient LARC patients.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers in this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.