Shared decision-making in radiotherapy for rectal cancer – A systematic review

Background: Shared decision-making (SDM) is increasingly emphasized in the ESMO guidelines for rectal cancer (RC). This review aim to describe the current landscape for SDM for radiotherapy (RT) in RC, investigate patient and clinician preferences regarding SDM and treatment options, and identify gaps in SDM for RT in RC. Methods: Following PRISMA guidelines, a systematic literature search was conducted in PubMed and EMBASE on June 4, 2025. Eligible studies investigated SDM, Patient Decision aids (PDA), and patient and clinician preferences regarding SDM related to RT for RC. Data extraction included study characteristics, interventions and outcomes. Risk of bias was assessed using the Mixed Methods Appraisal Tool. Results were synthesized narratively. Results: This review included 18 articles, 2 used SDM or developed PDAs, 5 explored patient preferences, 11 explored both patient and clinician preferences. Only a limited number of PDAs were available for RT in RC and none have yet been implemented or validated. Preferences differed between patients and clinicians. Patients valued sexual function and bowel outcomes more highly, while clinicians empathized survival and local control. Gender disparities were reported for patients. Patients preferred an active role in decision-making, but systematic SDM was infrequently used in clinical practice. Barriers included time constraints and infrequent use of SDM. Conclusion: Despite the complexity of decisions involving multiple treatment options and outcomes, no validated SDM tools exist for RT in RC, and significant gaps remain in development, implementation and use. Future research should focus on developing and implementing SDM and PDAs in clinical practice.