A modern approach to rectal cancer

Summary The management of rectal cancer has evolved considerably over the past few decades, resulting in improved patient outcomes. Along with enhancements in surgical techniques such as total mesorectal excision, the addition of multimodal radio- and chemotherapy protocols for specific tumor stages has played a significant role. More recent approaches include total neoadjuvant therapy protocols, which have increased the rates of complete clinical response and facilitated watch-and-wait strategies with non-operative management of the rectum. Immunotherapy for rare tumors characterized by microsatellite instability has also led to very high complete clinical response and rectum preservation rates. Decision-making is performed within specialized multidisciplinary tumor boards, considering various options such as primary tumor resection, neoadjuvant chemotherapy, neoadjuvant radiotherapy or chemoradiotherapy, and total neoadjuvant therapy for high-risk-disease patients. The aims of treatment beyond oncological cure include maintaining the integrity of urinary, stool, and sexual functions; avoiding a permanent stoma; and potentially preserving the rectum.