RAPIDO Trial Guidelines for Rectal Cancer

Recommended Treatment Approach

The National Comprehensive Cancer Network recommends a total neoadjuvant therapy approach consisting of short-course radiotherapy followed by full-dose chemotherapy before surgery for locally advanced rectal cancer with high-risk features, which significantly reduces disease-related treatment failure compared to standard chemoradiotherapy 1

Disease-related treatment failure at 3 years was 23.7% with the RAPIDO approach versus 30.4% with standard treatment, with a hazard ratio of 0.75 and a p-value of 0.019 1

The RAPIDO trial enrolled patients with MRI-defined high-risk features, including T4 tumors, threatened or involved mesorectal fascia, extramural vascular invasion, and low rectal tumors with threatened circumferential resection margin 2, 3

The NCCN recommends total neoadjuvant therapy as the preferred approach for stage II-III rectal cancer, but includes a specific caution that preoperative short-course radiotherapy may be associated with higher risk of local recurrence 1
Long-course chemoradiotherapy followed by consolidation chemotherapy is strongly preferred over short-course radiotherapy due to superior local control, with a 5-year locoregional failure rate of 6% versus 10% 1, 2

The RAPIDO approach is recommended for patients with high-risk features where systemic disease control is the primary concern, but should be avoided in patients where local control is paramount 1, 2
The American College of Surgeons and the National Comprehensive Cancer Network recommend that total mesorectal excision remains mandatory regardless of neoadjuvant approach, and that surgery should be performed 6-8 weeks after completion of neoadjuvant therapy 4, 5

Short-course radiotherapy should not be used when optimal local control is the priority, due to increased locoregional recurrence 1, 2
Accurate preoperative MRI staging is necessary to identify high-risk features that warrant total neoadjuvant therapy 5, 6