Neoadjuvant Chemoradiotherapy for Rectal Cancer

Introduction to Treatment Approaches

For locally advanced rectal cancer, the standard approach is preoperative chemoradiotherapy with fluoropyrimidine-based chemotherapy concurrent with radiation therapy, followed by total mesorectal excision surgery and adjuvant chemotherapy, as recommended by the National Comprehensive Cancer Network 1, 2

For cT1-2, N0 tumors, the European Society for Medical Oncology recommends proceeding directly to transanal excision or total mesorectal excision without neoadjuvant therapy 1
Upper rectal cancers should be treated as colon cancer without preoperative radiation, according to the European Society for Medical Oncology 1
For cT3 with clear mesorectal fascia, cN0-1, either short-course preoperative radiotherapy or standard chemoradiotherapy followed by total mesorectal excision is recommended by the European Society for Medical Oncology 1
If clinical complete response is achieved after chemoradiotherapy, a 'watch-and-wait' approach may be considered in high-risk surgical candidates, as suggested by the European Society for Medical Oncology 1

Capecitabine is a preferred option, with a demonstrated non-inferiority to 5-FU and improved 3-year disease-free survival, as recommended by the National Comprehensive Cancer Network 2, 3
Continuous infusion 5-FU is a standard dosing option during pelvic radiation, according to the National Comprehensive Cancer Network 2, 3

All patients with stage II/III rectal cancer should receive adjuvant chemotherapy after neoadjuvant chemoradiotherapy and surgery, regardless of pathological response, as recommended by the National Comprehensive Cancer Network 2, 5, 6
For higher-risk patients, FOLFOX or CAPEOX are preferred options, with improved 3-year disease-free survival, as recommended by the National Comprehensive Cancer Network 2, 5, 7

Patients achieving pathological complete response after neoadjuvant chemoradiotherapy have excellent outcomes, but adjuvant chemotherapy is still recommended, as suggested by the National Comprehensive Cancer Network 5, 7

A watch-and-wait approach may be considered in patients achieving clinical complete response after chemoradiotherapy, with careful patient selection and vigilant surveillance, as recommended by the European Society for Medical Oncology and the National Comprehensive Cancer Network 1, 6