Total neoadjuvant therapy in rectal cancer: Challenging traditions without compromising surgical safety

Abstract

Total neoadjuvant therapy (TNT) is swiftly transforming the therapeutic approach for locally advanced rectal cancer; yet, its integration as a standard practice necessitates meticulous evaluation of surgical safety, long-term outcomes, and patient-centered considerations. The research conducted by Jabbar et al offers an extensive evaluation of the preliminary surgical outcomes of patients using the Rectal Cancer and Preoperative Induction therapy followed by Dedicated Operation based TNT regimen in contrast to conventional long-course chemoradiotherapy. Their data indicate that TNT does not elevate operational complexity, create issues, or negatively affect the quality of oncologic resection, even with a prolonged interval between neoadjuvant therapy and surgery. Conversely, TNT correlated with a reduction in overall stoma duration and the incidence of persistent stomas, data that hold significant implications for postoperative quality of life. This study supports the increasing evidence that TNT is a safe and effective method for enhancing systemic control without negatively impacting surgical performance. However, its retrospective single-center approach restricts external validity, and long-term oncological consequences remain undetermined. The retrospective design presents potential confounders, including selection bias and variability in surgical skill. The experience of surgeons and institutional protocols may impact outcomes, highlighting the necessity for consistent surgical quality indicators in upcoming trials. As TNT begins to solidify its status as a novel treatment standard, multicenter studies and translational research will be essential in the future to determine its effects on survival, functional recovery, and organ preservation. Concerns persist over the long-term toxicity linked to increased chemotherapy regimens, including neuropathy and hematologic consequences. The financial implications of TNT, difficulty in patient adherence, and the danger of overtreatment underscore the importance of rigorous patient selection and thorough supportive care techniques. The study by Jabbar et al contributes to the growing body of literature demonstrating that TNT can be safely incorporated into the modern care of rectal cancer, signifying a notable progression towards individualized and patient-centered multimodal therapy.

Keywords: Total neoadjuvant therapy; Rectal cancer; Chemoradiotherapy; Total mesorectal excision; Rectal Cancer and Preoperative Induction therapy followed by Dedicated Operation trial; FOLFIRINOX; Organ preservation; Surgical safety; Multimodal therapy; Oncology

Core Tip: Total neoadjuvant therapy (TNT) signifies an advancing standard in the treatment of locally advanced rectal cancer, incorporating systemic chemotherapy prior to surgery and radiotherapy. Recent research, including the Rectal Cancer and Preoperative Induction therapy followed by Dedicated Operation based TNT regimen evaluated by Jabbar et al, indicates comparable oncologic safety, comparable oncologic safety and promising postoperative quality-of-life improvements. This editorial synthesizes known data on TNT’s effectiveness, tolerability, and promise for organ preservation, while highlighting ongoing discussions about treatment sequencing, fibrosis risk, and long-term results. The discussion highlights the significance of meticulous patient selection and multidisciplinary supervision in enhancing rectal cancer treatment via personalized, patient-focused multimodal therapy.