Locally advanced rectal cancer: what patients and practitioners should know about non-operative management

For decades, the standard of care for locally advanced rectal cancer (LARC) has consisted of rectal surgery combined with chemoradiotherapy, saving many lives but often impairing long-term quality of life. Recently, emerging evidence shows that, for up to 40% of patients, surgery may no longer be needed. Non-operative management (NOM), also known as watch-and-wait, allows patients whose tumours completely regress after treatment (whether immunotherapy or total neoadjuvant therapy) to be safely monitored without mandatory surgery; avoiding time and cost of major surgery and preserving both the rectum and quality of life. NOM is part of a broader trend in oncology: from a one-size-fits-all strategy to treatment de-escalation for those who do not need maximal intervention. In mismatch repair proficient/microsatellite stable (pMMR/MSS) LARC, this de-escalation has been paradoxically achieved by initial intensification using total neoadjuvant therapy to later omit surgery. This Viewpoint aims to outline for a broad medical audience, including non-specialist physicians and individuals in care, how recent advances are reshaping rectal cancer treatment. By discussing NOM as an opportunity to move beyond a purely surgical paradigm, we hope to increase awareness of NOM options to inform evidence-based decision-making, reduce treatment-related morbidity, and promote patient-centred models of care and shared decision-making.