The National Comprehensive Cancer Network (NCCN) has released updated rectal cancer practice guidelines. The Rectal Cancer Committee wants to alert ASCRS members of these changes in practice recommendations and has called out the following highlights from the NCCN Guidelines:
 

1. MMR/MSI
   1. All rectal cancers must be tested for MMR/MSI status
   2. Treatment algorithms for clinical stage II, III, IV rectal cancers are now stratified by MMR/MSI status, recognizing the role of immunotherapy

 

2. Malignant polyps and local excision cases
   1. For Low risk rectal malignant polyps no imaging is recommended (pedunculated, no adverse histologic features)
   2. For local excision, tumor budding is considered a “high risk” feature, along with >3 cm in size, >pT1, grade 3, lymphovascular invasion, positive margin, or sm3 (lower one third of the submucosa) depth of tumor invasion

 

3. Changes for lower-risk stage II and III cases
   1. The option of surgery only for T3N0 low-risk, upper rectal cancer is added
      1. “upper” is not defined, but most centers are defining “upper” as tumors completely above the anterior peritoneal reflection, which is usually visible on MRI
      2. “low risk” is not defined
   2. For patients who did not receive neoadjuvant therapy, the guidelines endorse the option of NO post-surgery RT for pT1-3, N1 and pT3N0 cases (adjuvant chemo only)

 

4. Neoadjuvant therapy
   1. TNT is the only option for clinical stage II/III rectal cancer
   2. FOLFIRINOX is added as a standard option in the neoadjuvant setting (and is preferred over FOLFOXIRI)
   3. for clinical stage II/III dMMR/MSI-H cancers, the “preferred” neoadjuvant therapy is checkpoint inhibitor immunotherapy

 

5. Watch and Wait
   1. WW is now an endorsed treatment option for patients with clinical complete response after neoadjuvant therapy
   2. WW is endorsed after BOTH standard total neoadjuvant therapy and after immunotherapy for dMMR/MSI-H tumors
   3. A recommended WW Surveillance Schedule has been added to the guidelines

 

6. Metastatic RC patients
   1. consider PET-CT in addition to standard imaging for potentially resectable metastatic RC
   2. all stage IV patients should have RAS, BRAF, HER2 testing in addition to MMR/MSI (extended molecular profile testing or otherwise)
   3. all metastatic RC patients are recommended to receive chemotherapy prior to surgery (exception of surgery to relieve symptomatic obstruction in selected cases)

 

7. ctDNA testing still not standard care, but the guidelines recommend participating in ctDNA trials

 

8. Fertility risk counseling emphasized

 
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