Prior to the introduction of preoperative treatment and modern surgical technique, recurrence rates for locally advanced rectal cancer ranged from 30% to 50%. Since the widespread adoption of total mesorectal excision and preoperative chemoradiation therapy (CRT), local recurrence rates have reduced considerably to only 5-10%. However, preoperative treatment comes at a cost with significant acute and late toxicity. Additionally, 2 standards of care have emerged-1 week of radiation alone vs 5 weeks of concurrent chemoradiation. In this review, we evaluate toxicity associated with preoperative treatment as well as the key pathological factors that influence outcome in patients with locally advanced rectal cancer. Additionally, we discuss endorectal brachytherapy, an alternative preoperative treatment that may result in equivalent or improved response rates with less toxicity when compared to conventional CRT.
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