Could the surgeon trust to radiotherapy help in rectal cancer?

When the surgeon analyzes the ongoing literature on the evidence of the neoadjuvant approaches to rectal cancer finds a true paradox: from one side they seem to offer a relative less relevant contribute through the time, in fact whereas in the Swedish trial preoperative radiation yielded a significant improvement of local control and survival, after the introduction of TME the contribution of preoperative chemoradiation is relegate to local control with no or poor influence on survival, even if the absolute 5-year survival rate moved from 40% of the ’70 to 60-65% of the latest years1-3. From other side the growing evidence of an incidence of pCR approaching to 30%4, seems to identify a subset of patients with more favorable prognosis to neoadjuvant treatments5-6. Furthermore, the overall evidence that 30- 35% of rectal cancer patients treated with multimodality therapy still die from cancer namely by distant metastases in spite of the 4-8 % of absolute benefit of adjuvant 5Fu based adjuvant chemotherapy7, seems to vanish the efforts of the further optimization of the local treatments (surgery and radiotherapy) and of the ongoing modality of delivery the chemotherapeutic agents. We would like to address the main evidences from the literature and the main uncertainties that the surgeon could face to propose a combined treatment to his rectal cancer patient.