Top Line: For small, node-negative rectal cancers, can we spare the rectum entirely, and does it matter whether we get there with long-course chemoRT or short course RT?
The Study: Surgery remains the standard for low risk rectal cancer, but some patients run the risk of colostomy, surgical complications, and sexual dysfunction despite completely responding to neoadjuvant therapy. STAR-TREC was a randomized trial that sought to determine if LCCRT or SCRT had better chances of organ preservation for patients with low risk rectal cancer. It included 409 patients with MRI stage T1-T3bN0 rectal adenocarcinoma (≤4 cm, mrN0, no EMVI, and clear mesorectal fascia). They were allowed to choose between organ preservation or surgery. Those who chose organ preservation were randomized to LCCRT organ preservation (50 Gy/25 fx with concurrent capecitabine) or SCRT organ preservation (25 Gy/5 fx, notably without consolidation chemotherapy), using a mesorectal-only target volume. A prespecified response-adapted pathway triaged patients to watch-and-wait for cCR, selective transanal excision for near-cCR, and TME otherwise. Among those who chose organ preservation, 12-month TME-free survival was higher with LCCRT (78.5% v 60.6%), driven by a higher cCR rate (64% v 36%) and less residual ypT2–3 disease (15% vs 37%). Grade 3+ adverse effects favored organ preservation over TME (8% vs 19%), with one postoperative death after anastomotic leak. The actual primary endpoint, organ preservation at 30 months, is still pending. Important to note is that this approach was specifically not TNT, and the goal was organ preservation for lower risk patients without the treatment intensity of TNT.
TBL: Within a response-adapted pathway for early rectal cancer, long-course chemoRT downstaged better than short course RT and preserved more rectums at one year. | Bach, Lancet Oncol 2026
The Study: Surgery remains the standard for low risk rectal cancer, but some patients run the risk of colostomy, surgical complications, and sexual dysfunction despite completely responding to neoadjuvant therapy. STAR-TREC was a randomized trial that sought to determine if LCCRT or SCRT had better chances of organ preservation for patients with low risk rectal cancer. It included 409 patients with MRI stage T1-T3bN0 rectal adenocarcinoma (≤4 cm, mrN0, no EMVI, and clear mesorectal fascia). They were allowed to choose between organ preservation or surgery. Those who chose organ preservation were randomized to LCCRT organ preservation (50 Gy/25 fx with concurrent capecitabine) or SCRT organ preservation (25 Gy/5 fx, notably without consolidation chemotherapy), using a mesorectal-only target volume. A prespecified response-adapted pathway triaged patients to watch-and-wait for cCR, selective transanal excision for near-cCR, and TME otherwise. Among those who chose organ preservation, 12-month TME-free survival was higher with LCCRT (78.5% v 60.6%), driven by a higher cCR rate (64% v 36%) and less residual ypT2–3 disease (15% vs 37%). Grade 3+ adverse effects favored organ preservation over TME (8% vs 19%), with one postoperative death after anastomotic leak. The actual primary endpoint, organ preservation at 30 months, is still pending. Important to note is that this approach was specifically not TNT, and the goal was organ preservation for lower risk patients without the treatment intensity of TNT.
TBL: Within a response-adapted pathway for early rectal cancer, long-course chemoRT downstaged better than short course RT and preserved more rectums at one year. | Bach, Lancet Oncol 2026