NCCN Guidelines® Insights: Rectal Cancer, Version 3.2024

Featured Updates to the NCCN Guidelines

Authors:
Al B. Benson III Robert H. Lurie Comprehensive Cancer Center of Northwestern University

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Alan P. Venook UCSF Helen Diller Family Comprehensive Cancer Center

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Mohamed Adam UCSF Helen Diller Family Comprehensive Cancer Center

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George Chang The University of Texas MD Anderson Cancer Center

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Yi-Jen Chen City of Hope National Medical Center

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Kristen K. Ciombor Vanderbilt-Ingram Cancer Center

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Stacey A. Cohen Fred Hutchinson Cancer Center

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Harry S. Cooper Fox Chase Cancer Center

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Dustin Deming University of Wisconsin Carbone Cancer Center

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Ignacio Garrido-Laguna Huntsman Cancer Institute at the University of Utah

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Jean L. Grem Fred & Pamela Buffett Cancer Center

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Paul Haste Indiana University Melvin and Bren Simon Comprehensive Cancer Center

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J. Randolph Hecht UCLA Jonsson Comprehensive Cancer Center

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Sarah Hoffe Moffitt Cancer Center

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Steven Hunt Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine

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Hisham Hussan UC Davis Comprehensive Cancer Center

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Kimberly L. Johung Yale Cancer Center/Smilow Cancer Hospital

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Nora Joseph University of Michigan Rogel Cancer Center

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Natalie Kirilcuk Stanford Cancer Institute

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Smitha Krishnamurthi Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute

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Midhun Malla O’Neal Comprehensive Cancer Center at UAB

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Jennifer K. Maratt Indiana University Melvin and Bren Simon Comprehensive Cancer Center

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Wells A. Messersmith University of Colorado Cancer Center

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Jeffrey Meyerhardt Dana-Farber Cancer Institute

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Eric D. Miller The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute

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Mary F. Mulcahy Robert H. Lurie Comprehensive Cancer Center of Northwestern University

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Steven Nurkin Roswell Park Comprehensive Cancer Center

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Aparna Parikh Mass General Cancer Center

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Hitendra Patel UC San Diego Moores Cancer Center

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Katrina Pedersen Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine

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Leonard Saltz Memorial Sloan Kettering Cancer Center

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Charles Schneider Abramson Cancer Center at the University of Pennsylvania

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David Shibata The University of Tennessee Health Science Center

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Benjamin Shogan The UChicago Medicine Comprehensive Cancer Center

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John M. Skibber The University of Texas MD Anderson Cancer Center

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Constantinos T. Sofocleous Memorial Sloan Kettering Cancer Center

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Anna Tavakkoli UT Southwestern Simmons Comprehensive Cancer Center

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Christopher G. Willett Duke Cancer Institute

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Christina Wu Mayo Clinic Comprehensive Cancer Center

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Frankie Jones National Comprehensive Cancer Network

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Lisa Gurski National Comprehensive Cancer Network

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The determination of an optimal treatment plan for an individual patient with rectal cancer is a complex process. In addition to decisions relating to the intent of rectal cancer surgery (ie, curative or palliative), consideration must also be given to the likely functional results of treatment, including the probability of maintaining or restoring normal bowel function/anal continence and preserving genitourinary functions. Particularly for patients with distal rectal cancer, finding a balance between curative-intent therapy while having minimal impact on quality of life can be challenging. Furthermore, the risk of pelvic recurrence is higher in patients with rectal cancer compared with those with colon cancer, and locally recurrent rectal cancer is associated with a poor prognosis. Careful patient selection and the use of sequenced multimodality therapy following a multidisciplinary approach is recommended. These NCCN Guidelines Insights detail recent updates to the NCCN Guidelines for Rectal Cancer, including the addition of endoscopic submucosal dissection as an option for early-stage rectal cancer, updates to the total neoadjuvant therapy approach based on the results of recent clinical trials, and the addition of a “watch-and-wait” nonoperative management approach for clinical complete responders to neoadjuvant therapy.

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    Smith JJ, Strombom P, Chow OS, et al. Assessment of a watch-and-wait strategy for rectal cancer in patients with a complete response after neoadjuvant therapy. JAMA Oncol 2019;5:e185896.

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    Kong JC, Guerra GR, Warrier SK, et al. Outcome and salvage surgery following “watch and wait” for rectal cancer after neoadjuvant therapy: a systematic review. Dis Colon Rectum 2017;60:335345.

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  • 69.

    van der Valk MJM, Hilling DE, Bastiaannet E, et al. Long-term outcomes of clinical complete responders after neoadjuvant treatment for rectal cancer in the International Watch & Wait Database (IWWD): an international multicentre registry study. Lancet 2018;391:25372545.

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    Fernandez LM, Sao Juliao GP, Figueiredo NL, et al. Conditional recurrence-free survival of clinical complete responders managed by watch and wait after neoadjuvant chemoradiotherapy for rectal cancer in the International Watch & Wait Database: a retrospective, international, multicentre registry study. Lancet Oncol 2021;22:4350.

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  • 71.

    Verheij FS, Omer DM, Williams H, et al. Long-term results of organ preservation in patients with rectal adenocarcinoma treated with total neoadjuvant therapy: the randomized phase II OPRA trial. J Clin Oncol 2024;42:500506.

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