Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
Department of Radiation Oncology, Mount Sinai, New York, NY.
Am Soc Clin Oncol Educ Book. 2022 Apr;42:1-14. doi: 10.1200/EDBK_351411.
In the past 40 years, the treatment of locally advanced rectal cancer has evolved with the addition of radiotherapy or chemoradiotherapy and providing (neo)adjuvant systemic chemotherapy to major surgery. However, recent trends have focused on improving our ability to risk-stratify patients and tailoring treatment to achieve the best oncologic outcome while limiting the impact on long-term quality of life. Therefore, there has been increasing interest in pursuing a watch-and-wait approach to achieve organ preservation. Several retro- and prospective studies suggest safety of the watch-and-wait approach, though it is still considered controversial due to limited clinical evidence, concerns about tumor regrowth, and subsequent distant progression. To further reduce treatment, MRI risk stratification, together with patient characteristics and patient preferences, can guide personalized treatment and reserve radiation and chemotherapy for a select patient population. Ultimately, improved options for reassessment during neoadjuvant treatment may allow for more adaptive therapy options based on treatment response. This article provides an overview of some major developments in the multimodal treatment of locally advanced rectal cancer. It reviews some relevant, controversial issues of the watch-and-wait approach and opportunities to personally tailor and reduce treatment. It also reviews the overall neoadjuvant treatment, including total neoadjuvant therapy trials, and how to best optimize for a potential complete response. Finally, it provides an algorithm as an example of how such a personalized, tailored, adaptive, and reduced treatment could look like in the future.
在过去的 40 年中，局部晚期直肠癌的治疗方法随着放疗或放化疗的加入以及对主要手术进行（新）辅助全身化疗而不断发展。然而，最近的趋势集中在提高我们对患者进行风险分层的能力，并根据治疗效果对患者进行分层，以实现最佳的肿瘤学结果，同时限制对长期生活质量的影响。因此，越来越多的人对采用观察等待的方法来实现器官保留感兴趣。几项回顾性和前瞻性研究表明，观察等待方法是安全的，尽管由于临床证据有限、对肿瘤复发的担忧以及随后的远处进展，该方法仍存在争议。为了进一步减少治疗，MRI 风险分层，结合患者特征和患者偏好，可以指导个性化治疗，并为特定患者群体保留放疗和化疗。最终，新辅助治疗期间重新评估的选择可能会允许根据治疗反应选择更具适应性的治疗选择。本文概述了局部晚期直肠癌多模式治疗的一些主要进展。它回顾了观察等待方法的一些相关和有争议的问题，以及个性化治疗和减少治疗的机会。它还回顾了整体新辅助治疗，包括总新辅助治疗试验，以及如何优化潜在完全缓解的治疗。最后，它提供了一个算法作为示例，说明未来如何实现这种个性化、量身定制、适应性和减少的治疗。
