Challenges in the neoadjuvant treatment of rectal cancer: Balancing the risk of recurrence and quality of life

The management of patients with rectal cancer has improved substantially–assisted by refinements in surgical technique, the increasing accuracy of preoperative imaging, more precise delivery of radiotherapy¸and more informative feedback from the histopathologist. Multidisciplinary teams have been the key to this success. Future challenges facing multidisciplinary teams include individually tailoring therapy - in particular in deciding who does and does not need radiotherapy, utilising new radiotherapy techniques such as intensity-modulated radiotherapy and image-guided radiotherapy and new systemic therapies, and electing patients for whom chemoradiotherapy might be potentially curative without surgical resection after complete clinical response. Hence, there is an increasing focus on developing predictive and prognostic molecular biomarkers. This paper explores the background to common variations in practice, and the current and future challenges in the neoadjuvant treatment of rectal cancer.