Four steps in the evolution of rectal cancer managements through 40 years of clinical practice: pioneering, standardization, challenges and personalization

Introduction Over the last century, rectal cancer (RC) treatment has witnessed dynamic transformations, prominently influenced by advancements in surgery, radiotherapy (RT), and drug therapies. This retrospective analysis focuses on a 40-year mono-institutional experience, tracing the evolution of RC management through distinct phases. Materials and Methods A dedicated working group at Policlinico A. Gemelli University Hospital systematically collected data on 3753 non-metastatic RC patients treated from 1980 to 2022. Categorized into Pioneering, Optimizing, Challenges, and Personalizing phases, 3146 patients met inclusion criteria. Sixty coded neoadjuvant and adjuvant modalities were applied, and outcomes were assessed using oncological parameters and toxicity grading. Results Distinct phases, from 1980 to 2010, revealed evolving treatment approaches, with advancements in patient outcomes: increased sphincter salvage rates (from 29% to 86%), organ preservation (from 0 to 18%), emergence of pathological complete responses (from 0 to 30%), 5 years-overall survival (from 70% to 89.9% and from 20% to 88.9% in cT3 and cT4, respectively) and 5 years-local control (from 85% to 95% and from 80% to 93% in cT3 and cT4, respectively). The study elucidated treatment modalities' impact on patient outcomes, with each phase reflecting the iterative progress in RC care. Conclusions The phased analysis underscores a 40-year trajectory in RC treatment, demonstrating a continuous cycle of improvement in patient care. Pioneering efforts established feasibility, while subsequent phases optimized techniques, addressed challenges, and prioritized personalized approaches. The study contributes valuable insights for advancing individualized and effective RC management strategies, emphasizing the significance of multidisciplinary collaboration and data-driven innovation.These data were presented at the Jens Overgaard Legacy Award Lecture at the ESTRO 2023 congress, Vienna 13 May 2023.