Contemporary neoadjuvant strategies for rectal cancer: The GRECCAR snapshot study

AIM: Neoadjuvant treatment for rectal cancer has evolved markedly with the growing adoption of total neoadjuvant therapy (TNT), organ-preservation strategies and selective omission of radiotherapy. Recent trials support risk-based personalization, but its application in real-world settings remains poorly documented. The aim was to describe current neoadjuvant treatment practices for mid-low rectal cancer in French expert centres and identify tumour- and patient-related factors influencing decisions. METHOD: This observational study included patients with non-metastatic rectal adenocarcinoma ≤10 cm from the anal verge, discussed in tumour boards (October 2022 to March 2023) across GRECCAR centres. Tumours were classified as early, intermediate-risk or locally advanced rectal cancer (LARC). Neoadjuvant treatments were analysed according to tumour extension, location and age. RESULTS: Among 463 patients from 27 centres, the most frequent regimen was induction chemotherapy, mainly FOLFIRINOX, followed by long-course chemoradiotherapy (CRT) (65%). This approach was used in 51%, 66% and 71% of patients in the early, intermediate-risk and LARC groups, respectively (p = 0.0060). TNT was more frequently administered for low- than mid-rectal cancers, especially in LARC (86% vs. 71%, p = 0.016). In patients >75 years, CRT + consolidation chemotherapy and radiotherapy alone were proportionally more frequent. Among the early rectal cancers, those treated with induction chemotherapy + CRT had more advanced features than those treated with CRT alone (cT3: 80% vs. 43%, cN+: 62% vs. 10%, tumour size: 3.4 vs. 2.3 cm; all p < 0.001). CONCLUSION: TNT with induction chemotherapy is the predominant neoadjuvant approach in French expert centres. Tumour classification, location and patient age significantly influence treatment choices, reflecting a shift towards personalized context-specific care.