Curative therapy for rectal cancer

ABSTRACT

Introduction: A comprehensive trimodality approach has become the standard of care for patients with locally advanced rectal cancer. However, the sequencing and duration of chemotherapy and chemoradiotherapy around surgery varies between clinical studies and geographical regions. Growing evidence is also mounting for strategies such as total neoadjuvant therapy and non-operative management for carefully selected patients.

Areas covered: We provide a perspective review of the current evidence and controversies in the treatment of locally advanced rectal cancer including the recent updates from the 2020 ASCO annual conference.

Expert opinion: With ongoing advances in the management of locally advanced rectal cancer, a multidisciplinary team approach is necessary as treatments could involve multiple approaches. Chemoradiotherapy whether short or long course followed by at least 3 months of systemic chemotherapy may be the preferred option to balance local and distant disease control. Albeit the choice of doublet or triplet chemotherapy is still controversial. As total neoadjuvant treatment becomes part of the standard of care in rectal cancer, modification of the surveillance schedule is needed to detect early recurrences which may be limited by resources and availability of services.

KEYWORDS:

• Chemotherapy
• chemoradiotherapy
• rectal cancer
• pathologic complete response rate
• total neoadjuvant therapy

Article highlights

• The treatment plan of locally advanced rectal carcinoma requires a multidisciplinary approach in planning and management.

• Preoperative chemoradiotherapy whether long or short course has become the standard treatment for locally advanced rectal cancer.

• The use of adjuvant chemotherapy in locally advanced rectal cancer was extrapolated from results showing improved DFS and OS in colon cancer. Poor tolerance to adjuvant chemotherapy in rectal cancer lead to increased interest in preoperative chemotherapy administration.

• Total neoadjuvant chemotherapy is gaining more interest due to the increased pCR rates with the watch and wait approach although is not standard of care is emerging as a new pathway for patients.

• The PRODIGE23, OPRA and RAPIDO studies provide three different approaches to the management of locally advanced rectal cancer with the principle of early introduction of combination chemotherapy.

• The sequence of Chemoradiotherapy followed by combination chemotherapy for at least 3 months may be the preferred approach but the optimal regimen whether a doublet or triplet chemotherapy is yet to be defined.

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 on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper received no funding.