Neoadjuvant short-course radiation therapy (i.e., 25 Gy across five fractions) was rated Appropriate for many intermediate- and moderately-high-risk cases with non-threatened mesorectal margins and May Be Appropriate for other scenarios. While short-course radiation is the standard of care for moderately-advanced cases in many Northern European countries, it is rarely used in the U.S., said Goodman, yet she sees this option as gaining traction domestically, as evidenced in part by the recommendations of this panel.

For adjuvant therapy, panelists assessed two treatment options, chemotherapy alone and chemoradiation plus four or more months of chemotherapy, stratified by three patient characteristics: circumferential resection margin, distance from the anal verge and risk classification based on total postsurgical nodal count.


Adjuvant chemoradiation therapy (CRT) plus chemotherapy was rated Appropriate for all patients with positive margins and for patients with negative margins but higher risk classification and/or lower tumors. Adjuvant chemotherapy alone was rated Appropriate only for patients with negative margins, moderately-high-risk disease and higher tumors; it was rated May Be Appropriate for all other scenarios.

For medically inoperable cases (e.g., elderly patients who are not strong surgical candidates), panelists considered five non-operative treatment sequences, stratified by three patient characteristics: performance status based on Eastern Cooperative Oncology Group score, presence or absence of local symptoms and distance from the anal verge.

Chemoradiation was rated Appropriate for medically inoperable patients with good performance status and May Be Appropriate for those with poor performance status. External beam radiotherapy (EBRT) alone and chemotherapy alone were rated May Be Appropriate for all scenarios. Brachytherapy alone and brachytherapy combined with CRT were rated potentially appropriate for lower tumors but rarely appropriate for higher tumors.

The guidelines also assess definitive non-operative treatment for patients who experience a pathologic complete response following neoadjuvant chemoradiation and want to avoid radical surgery, particularly those with low-lying tumors who are at higher risk for a permanent colosotomy. Panelists considered three treatment options, including standard-dose chemoradiation alone, chemoradiation plus brachytherapy boost and chemoradiation plus EBRT boost. Each approach was rated Appropriate for scenarios where patients refuse standard therapy.

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