Navigating Complex Choices in Locally Advanced Rectal Cancer: A Review of Patient Decision-Making, Shared Decision-Making Models, and Future Directions

Abstract Decision-making in oncology is uniquely challenging, requiring patients to interpret complex information, weigh uncertain outcomes, and balance survival with quality-of-life considerations. In locally advanced rectal cancer, evolving treatment options such as total neoadjuvant therapy, selective radiation, and nonoperative management via watch-and-wait have made decision-making increasingly nuanced. These choices are preference-sensitive, meaning the optimal approach depends not on a single clinical standard but on the patient's values, goals, and risk tolerance. This review explores how patients navigate key decision points in locally advanced rectal cancer management. We examine individual-level factors that shape decision-making and describe how patients process trade-offs between oncologic risk and functional outcomes. The review also discusses models that support patient decision-making and outlines future directions for research, clinical training, and the development of tools to better understand and meet patients' decisional needs.