For locally advanced rectal cancer, would you consider utilizing the RAPIDO trial approach of short course radiation followed by neoadjuvant chemotherapy prior to surgery?

RAPIDO trial is an important study since it is the first phase III study that reported final results of a total neoadjuvant treatment (TNT) approach for rectal cancer.

The RAPIDO study is a European study and we need to be aware of the practice difference (in the US, we traditionally use neoadjuvant long course chemoradiation while in Europe, short-course radiation 5Gy X5 is the standard of care). The eligibility criteria in the RAPIDO study is trying to enroll patients with high-risk rectal canc...

I need to disagree with Dr. @Dr. First Last, who I think has misquoted the local-regional failure rate in the two treatment arms. The 17% vs 10% local failure that he quotes is the percent of patients with LR recurrence in the patients who recurred. If there are fewer distant mets with TNT, then there is very likely to be a higher percentage of LR failure in the patients who recurred. The correct percentages to use are the LR failure rate in the total population and that was 8% vs 6% (in favor o...

Nice discussion. I think the elephant in the room is the distant/systemic failure, which kills most patients who die from rectal cancer. It is hard to infer the impact of systemic therapy from the RAPIDO trial data. However, the UNICANCER-PRODIGE 23 data provide direct evidence that 'Intensification of chemotherapy using FOLFIRINOX before preoperative chemoradiotherapy significantly improved outcomes compared with preoperative chemoradiotherapy in patients with cT3 or cT4 M0 rectal cancer.' Our ...

Thanks a lot for the great input @Dr. First Last and @Dr. First Last.

RAPIDO, although enrolled 20 US patients, the study design and vast majority of the patients were in Europe and I would pay more attention to the enrollment criteria which is clearly consistent with ESMO guidelines which is quite different from US.

The optional adjuvant chemotherapy in my mind is the key component that potentially flawed the interperatation of the study findings. Adjuvant chemotherapy is an important component...

Very animated and indeed enjoyable discussion as it highlights the controversy surrounding the current management of locally advanced rectal cancer and although, we have made strides in the past two decades or so in this disease, we still have work to do. Thanks to all for your various perspectives.