Total neoadjuvant therapy for each local advanced rectal cancer?

The treatment paradigm for locally advanced rectal cancer has changed in recent years. Neoadjuvant radiochemotherapy followed by total mesorectal excision and postoperative chemotherapy has been the standard of care since many years. With this multidisciplinary approach the local recurrence rate is low, but the occurrence of distant metastases and impairments of quality of life due to bowel, bladder, and sexual dysfunction are still unresolved problems. The integration of induction or consolidation chemotherapy into the neoadjuvant setting, a watch-and-wait strategy without surgery for patients with clinical complete response, the integration of immunotherapy into the neoadjuvant setting in microsatellite-instable rectal cancer as well as the selective omission of neoadjuvant radiotherapy now represent different treatment options and enable individualization of therapy for locally advanced rectal cancer. Here, we provide an overview of the latest developments in the treatment of locally advanced rectal cancer and a discussion on which patients need more intensive or less intensive therapy.