Risk management.

In 2014, in a move progressive far beyond the NCCN, the Netherlands implemented national guidelines for rectal cancer neoadjuvant therapy stratified by MR-guided disease characteristics much more descriptive than TNM stage alone. As established in the MERCURY, et al trials: High-risk is defined as cN2 or any disease within 1 mm of mesorectal fascia and is recommended to receive standard upfront chemoradiation, intermediate-risk is defined as cN1 or >5 mm invasion beyond rectal wall but >1 mm from mesorectal fascia and is recommended to receive short-course radiation alone if >5 cm above anal verge, and low-risk includes all lesser disease (even high-lying cT3) and is recommended to receive upfront surgery. How has it played out? Across >25K patients in this Dutch cancer registry study, the rate of low-risk tumors not undergoing neoadjuvant radiation increased from 31% pre-guideline to 91% post-guideline with no decipherable impact on survival. TBL: The Dutch are successfully becoming more judicious in their employment of neoadjuvant treatment for rectal cancer. | Koëter, Radiother Oncol 2020