Multidisciplinary Management of Locally Advanced Rectal Cancer--An Evolving Landscape?

For many years, the multidisciplinary approach of neoadjuvant radiotherapy with or without concurrent chemotherapy followed by total mesorectal excision and adjuvant fluoropyrimidine chemotherapy has remained the accepted standard management for locally advanced rectal cancers. Over this time period, many new systemic treatment options have become available, including: additional chemotherapeutic agents (oxaliplatin) and targeted therapies (vascular endothelial growth factor and epidermal growth factor receptor inhibitors), which can be added to neoadjuvant and adjuvant regimens or given in combination with radiotherapy as radio-sensitizing agents. Here we review the current literature, examining emerging data related to the impact of multiple modifications to the standard approach, including the role of neoadjuvant chemotherapy, the addition of new agents to standard chemoradiation, and postoperative fluoropyrimidine-based treatment, the optimal timing of surgery, and nonoperative approaches to the management of locally advanced rectal cancers.