Upfront Surgery Vs Total Neoadjuvant Therapy in Rectal Cancer

In this video, Ryan Moore, MD, a colorectal surgeon at Hackensack University Medical Center, part of Hackensack Meridian Health, discusses how clinicians determine whether patients with rectal cancer should undergo upfront surgery or total neoadjuvant therapy (TNT).

According to Moore, tumor location within the rectum is a primary driver of this decision. When a tumor is situated high in the rectum, surgeons can typically operate safely, remove the cancer, and reconnect the intestines, making upfront surgery the preferred approach. Tumors located low in the rectum, close to the anus or sphincter muscles, make TNT a more likely consideration. TNT is also favored when a tumor is large, involves adjacent structures, or when surgery would otherwise require a permanent colostomy.

Moore noted that nearly all patients who have a clinical complete response to neoadjuvant therapy are candidates for watch-and-wait, an organ-preserving strategy that allows appropriate patients to avoid surgery altogether, provided they are willing to return for regular follow-up and adhere to the surveillance protocol. Following completion of TNT, patients are restaged with MRI, CT scans, and either flexible sigmoidoscopy or colonoscopy to evaluate treatment response. Patients who achieve a complete response, with no remaining evidence of tumor, can be enrolled in the watch-and-wait protocol rather than proceeding directly to surgery.

Patients on watch-and-wait are monitored closely, with follow-up visits occurring every 3 months to check for recurrence or other changes. Moore emphasizes that these patients remain closely engaged with their care team throughout surveillance, which helps ensure that any signs of regrowth are caught early. If imaging or endoscopic findings change during follow-up, patients are moved off the watch-and-wait protocol and transitioned to standard treatment, which at that point generally means surgery.

Moore’s comments underscore the increasingly individualized approach to rectal cancer management, in which tumor location, size, and involvement of surrounding structures, not a one-size-fits-all algorithm, guide clinical decisions.