[Rectal cancer: Towards personalized medicine]

The standard of care for patients with locally advanced rectal cancer has recently changed and is now based on the concept of total neoadjuvant therapy with the association of radiotherapy and systemic chemotherapy before radical surgery. The addition of noeadjuvant systemic chemotherapy before or after radiotherapy during preoperative course significantly decreased the risk of distant metastases and prolonged disease-free survival after surgery. The risk of recurrence varies among patients and the standard management associating chemotherapy, radiotherapy and surgery may expose many patients to overtreatment and can negatively affect quality of life. In this setting, several ongoing trials evaluate the possibility of less aggressive individually tailored approach based on omission of one of three treatments. In particular, NORAD and PROSPECT trials evaluate whether irradiation could be safely omitted in patients who are good responders to induction chemotherapy and have locally advanced primarily resectable tumor with large predictive circumferential resection margin. In the other hand, the total neoadjuvant therapy had significantly improved the pathological complete response rate, up to 30%, leading the concept of non-operative management and organ-preserving strategies. The phase III GRECCAR 12 study has therefore evaluated the potential benefit of intensification of neoadjuvant chemotherapy whereas OPERA and MORPHEUS trials assessed radiotherapy dose escalation by contact X-ray or brachytherapy for organ-preserving strategies. To date, total neoadjuvant therapy following by radical surgery remains the standard of care but probably less aggressive approach with omission of radiotherapy or surgery will become a new standard in selected patients in next future.