The options available for the surgeon treating patients with
rectal cancer have multiplied over the last decade, allowing varied approaches to the disease for individual patients. The development of effective adjuvant
therapy in the form of
radiotherapy and
chemotherapy has led to exciting results-and yet more questions to be answered. The decision to employ adjuvant
therapy has led to the development of better staging modalities to improve patient selection for the various treatment protocols. The basic issue of timing of
therapy-preoperative vs. postoperative-remains hotly contested, and good, prospective, randomized trials are needed before the questions can be answered. The utility of preoperative multimodality
therapy in the downstaging of
tumors to make curative resection or sphincter preservation possible must be examined. Advances in surgical
therapy have been significant, and groups have reported excellent results with total mesorectal excision (TME) in patients without the addition of adjuvant
therapy. Other important surgical issues include ultralow anterior resections with colo-anal or
J-pouch anal anastomosis, and the efficacy of sphincter preservation through local excision of invasive
rectal cancers with or without adjuvant
therapy. Each of these issues needs further study and will have great impact on the treatment of
rectal cancer as further experience is gained.