The American Society of Clinical Oncology conducted a systematic review of research from 2013 to 2023—led by Aaron J. Scott, MD, and colleagues and published in the Journal of Clinical Oncology—and released new recommendations for the management of locally advanced rectal cancer.
The systematic review included data from 12 randomized controlled trials, 2 systematic reviews, and 1 nonrandomized study. For the study, expert panel members created evidence-based guideline recommendations for clinicians based on available evidence and informal consensus.
The society’s recommendations encouraged patients with microsatellite stable or proficient mismatch repair locally advanced rectal cancer who have undergone assessment with magnetic resonance imaging to consider total neoadjuvant therapy (TNT) as initial treatment for tumors in the lower rectum. They also encouraged those who are at a higher risk of local or distant metastases to consider TNT.
Patients who do not present with high-risk factors are eligible to receive chemotherapy with selective chemoradiation (CRT) dependent upon the extent of response, TNT, neoadjuvant long-course CRT, or short-course radiation.
Those who are eligible for TNT should undergo chemotherapy following radiation, with neoadjuvant long-course CRT being preferable over short-course radiation therapy (RT). Investigators noted that short-course RT can be a viable treatment variation for some patients.
The society also noted that clinicians may offer nonoperative management instead of total mesorectal excision for patients who demonstrate a clinical complete response to neoadjuvant therapy. Immunotherapy is the recommended treatment for patients with tumors presenting with microsatellite instability-high or mismatch repair-deficient disease.
Dr. Scott and colleagues noted that the expert panel is monitoring several current studies, including the JANUS rectal cancer trial, the phase 3 ENSEMBLE trial, and the COMET study.
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