Optimizing neoadjuvant immunotherapy in rectal cancer

The integration of immune checkpoint inhibitors (ICIs) into neoadjuvant strategies is increasingly being studied in locally advanced rectal cancer (LARC), to improve complete response (CR), organ preservation, and potentially overall survival (OS). However, the clinical impact of conventional PD-1 blockade still remains limited in proficient mismatch repair/microsatellite-stable (pMMR/MSS) disease, suggesting that its simple addition to standard neoadjuvant therapy may be insufficient. By contrast, deficient mismatch repair/microsatellite instability-high (dMMR/MSI-H) rectal cancer displays marked sensitivity to PD-1 blockade, enabling non-operative management in a substantial proportion of patients, although primary resistance and incomplete responses are increasingly recognized. In this review, we critically discuss the available randomized evidence and the biological determinants of response to neoadjuvant immunotherapy, with particular focus on pMMR/MSS disease. We examine the role of pre-existing antitumor immunity and potential biomarkers such as PD-L1 and Immunoscore, as well as how radiotherapy integration, novel ICIs, and immune-sensitizing strategies may enhance ICI efficacy. Finally, we also address emerging challenges in dMMR/MSI-H rectal cancer and potential strategies to overcome resistance. Moving from empiric ICI addition toward biologically informed and rationally designed immune-based strategies may represent the next step to maximize complete response and organ preservation in rectal cancer.