Challenges in Organ-Sparing Approaches to Rectal Cancer

Carla F. Justiniano, MD, MPH, FACS, FASCRS

Rectal cancer management has changed greatly over the past 25 years. Surgically, the broad acceptance of total mesorectal excision principles and new surgical techniques, including minimally invasive surgery have led to improvements in local recurrence. Transanal platforms for local excision of complex lesions, even in the mid-rectum, became the first way to achieve organ-preservation in early cancers. Medically, there has been a shift from “sandwich” chemotherapy, which utilized neoadjuvant chemoradiation followed by surgery and then adjuvant chemotherapy, toward total neoadjuvant treatment (TNT) with chemoradiation, which led to improvements in survival and the advent of watch-and-wait protocols allowing for organ preservation in locally advanced cancers.

While the increasing adoption of TNT and watch-and-wait protocols brings hope to many patients in deferring surgery, this is not without risks, warranting thoughtful considerations on behalf of providers and patients. In this issue of Clinics in Colon and Rectal Surgery (“Challenges of Organ-Sparing Approaches to Rectal Cancer”), we explore current areas of decision-making in rectal cancer that warrant special consideration, including at the provider level, comprising treatment response assessment and consideration of regrowth risks. Importantly, this issue also incorporates the patient perspective and how providers can approach “watch-and-wait” conversations in discussing deferred surgery and its risks with patients who are eligible. Moreover, the question of how well “watch-and-wait” patients are being watched becomes ever more important as it is increasingly adopted and is even incorporated into National Comprehensive Network guidelines; yet, not all hospitals and systems have strong infrastructure to surveil and “watch” vigilantly.

I would like to express my deepest appreciation to Dr. Scott Steele for the opportunity to serve as guest editor for this edition dedicated to rectal cancer. Dr. Steele was an influential mentor during my training and continues to be during my career, and I remain grateful for his guidance and support.

Lastly, I am deeply indebted to the distinguished experts in rectal cancer who graciously contributed to this issue, encompassing surgeons and medical oncologists. Their thoughtful examination of these topics, grounded in the best available evidence and informed by extensive experience, brings clarity and insight into our everyday decision-making with patients and within our multidisciplinary tumor boards.

Publication History

Article published online:
09 January 2026