Changes in Multidisciplinary Management of Locally Advanced Rectal Cancer at a Comprehensive Cancer Center From 2015 to 2023

BACKGROUND: Multidisciplinary management of locally advanced rectal cancer (LARC) has evolved rapidly over the past decade, guided by data from multiple prospective clinical trials. METHODS: Changes in treatment of cT3-4 or N+ rectal cancer at a comprehensive cancer center between 2015 and 2023 were analyzed retrospectively. RESULTS: Of 1121 patients who received neoadjuvant therapy, 793 (71%) underwent active surveillance and 328 (29%) underwent surgery within 3 months. Treatments whose use increased from 2015 to 2023 included TNT with consolidation chemotherapy (from 10% to 81%), neoadjuvant chemotherapy alone (from 13% to 21%), immunotherapy or targeted therapy (from 0% to 10%), and oral capecitabine versus intravenous fluorouracil in combination with oxaliplatin (from 4% to 56%). Among patients who received TNT, nonoperative management with sustained clinical complete response rose from 38% to 50%. With more patients undergoing nonoperative management, the rate of pathologic complete response decreased from 22% to 8.3%. Robotic assistance was used in 88% of surgeries. CONCLUSIONS: The adoption of new diagnostic and treatment paradigms allows for longer intervals until surgery, more frequent use of active surveillance, and higher rates of organ preservation without compromising safety or oncologic outcomes.