Evidence-Based De-Escalation of Radiotherapy in Locally Advanced Rectal Cancer

Advancements in cancer care have significantly extended the life expectancy of rectal cancer patients and the impact of treatment-related toxicity on long-term quality of life has become a crucial factor in determining the most suitable type of neoadjuvant therapy, particularly for patients who are likely to undergo surgery. While radiotherapy has traditionally been regarded as the cornerstone for achieving improved local control in rectal cancer, it is accompanied by a range of associated complications, including bowel and bladder dysfunction, gonadal ablation, and Low Anterior Resection Syndrome. De-escalation of treatment is undoubtedly beneficial for many patients, and this approach should be tailored to consider their expectations while prioritizing patient care in decision-making. Although there is inadequate data to support the oncologic safety of a watch-and-wait approach without radiation or to omit radiation in patients with suspicious lateral pelvic lymph nodes, sufficient evidence exists to justify de-escalation by avoiding radiation before surgery in many other patients who respond well to chemotherapy.