History of neoadjuvant therapy for rectal cancer

Management of rectal cancer has evolved extensively over the last 30 years. Treatment of locally advanced rectal cancer currently incorporates surgery, chemotherapy, and radiation. Radiation was initially utilized as a salvage method as historic surgical practices were associated with high morbidity rates. In present day, multiple studies have demonstrated that the use of radiation as an adjunct to surgery decreases local recurrence rates. The now routine practice of total mesorectal excision during rectal cancer surgery has further improved outcomes. Numerous studies have evaluated the chemotherapeutic regimens as adjuncts to radiation therapy. Currently, fluorouracil-based regimens are commonly incorporated into neoadjuvant therapy for locally advanced rectal cancer, whereas oxaliplatin has not been incorporated due to more recent studies demonstrating increased toxicity and no clear oncologic benefit. Presently, trials are underway that aim to tailor therapies to specific patterns of disease, in hopes of allowing clinicians to selectively omit components of therapy to limit toxicity and morbidity while maintaining or improving oncologic outcomes. Thus, rectal cancer treatment continues to evolve, and decision-making surround treatment remains highly individualized and nuanced.