Evolution and Current Status of the Multidisciplinary Management of Locally Advanced Rectal Cancer

Benjamin W. Deschner, MD; Noam A. VanderWalde, MD, MS; Axel Grothey, MD; David Shibata, MD


J Oncol Pract. 2021;17(7):383-402. 

In This Article

Abstract and Introduction


The management of locally advanced rectal cancer has grown in both complexity and quality since the first proctectomy. What once was a malignancy with a fairly consistent treatment algorithm for decades, a recent paradigm shift in the care of these patients has led to a more personalized, multidisciplinary approach with variations in timing, sequence, duration, and potential exclusion of multimodality therapies. This review summarizes the most important evidence behind these developing overarching concepts to provide a context for this paradigm shift.


Despite reductions in incidence and mortality, colorectal cancer persists as the third most common and second most lethal malignancy worldwide.[1] In the early 2000s, the standard of care in the United States for locally advanced rectal cancer (LARC) consisted of neoadjuvant chemoradiation followed by surgical resection and adjuvant chemotherapy.[2–4] Recently, several novel concepts are shaping new treatment paradigms, including changes in timing, sequence, and duration of therapies combined with potential de-escalation of treatment components. Consequently, numerous options now exist for individualization of treatment based on considerations such as tumor biology, tumor location, age, sex, quality of life, fertility, sexual function, functional status or comorbidities, bowel function, and treatment objectives. Indeed, complex guidelines such as those from the National Comprehensive Cancer Network (NCCN) demonstrate a shift toward personalization of care.[5]