International expert Delphi consensus on management of early and locally advanced rectal cancer

Treatment strategies for early and locally advanced rectal cancer are evolving, particularly with the increasing use of non-operative management and multidisciplinary decision-making. The aim of this study is to establish an expert-based consensus on the preferred treatment strategies for early and locally advanced rectal cancer.

A 12-member steering committee was established to conduct a modified Delphi consensus process on rectal cancer management. The committee performed a systematic literature review (2014-2024) to inform survey development. A 49-question survey, including open-ended and multiple-choice items, was developed and refined. A panel of 44 colorectal surgery experts was selected based on academic contributions, and two Delphi rounds were conducted anonymously. Consensus was defined as ≥ 70% agreement. Based on panel responses, 29 consensus statements were formulated.

The panel reached consensus on the importance of multidisciplinary evaluation and surgical expertise in total mesorectal excision. Structured MRI reporting was recommended. Total neoadjuvant therapy was preferred for high-risk tumors. Non-operative management was recommended in cases of clinical complete response, with defined surveillance strategies. The role of biopsy in near-complete responders was also addressed.

This international consensus provides structured guidance on the management of rectal cancer, emphasizing multidisciplinary planning, the role of total neoadjuvant therapy in organ preservation, and rigorous surveillance protocols in non-operative management. These recommendations aim to standardize care and support evidence-informed clinical decision-making.