Perspectives of the Use of Neoadjuvant Therapy in the Management of Locally Advanced and Locally Recurrent Colon Cancer: A Bi-National Survey of Colorectal Surgeons

Abstract

Background

Colorectal cancer is a significant global health burden, with locally advanced colon cancer (LACC) comprising up to 20% of cases and associated with high rates of local recurrence and distant metastases. Although neoadjuvant chemotherapy (NAC) is well established in several gastrointestinal malignancies, its role in LACC and locally recurrent colon cancer remains debated. This study aimed to assess the perceptions and current practices of colorectal surgeons in Australia and New Zealand regarding the use of neoadjuvant therapies in these settings.

Methods

A structured 16-question online survey was distributed via Qualtrics to 275 colorectal surgeons affiliated with the Colorectal Surgical Society of Australia and New Zealand (CSSANZ). The survey included demographic questions and 13 clinical scenarios addressing the management of LACC and locally recurrent colon cancer without distant metastases. Responses were collected over 1 month, with one reminder sent at 2 weeks. Data were analyzed using Microsoft Excel, and responses were presented as percentages with bar graphs illustrating management preferences.

Results

Ninety-seven surgeons (35.3% response rate) completed the survey; 86% were based in Australia and 70% had more than 5 years of consulting experience. Overall, 57% of respondents had previously employed neoadjuvant chemotherapy ± radiotherapy for non-metastatic LACC. In T4N0 disease, 54.3% opted for upfront resection, while 46% favored neoadjuvant strategies (29.4% chemotherapy and 16.3% chemoradiotherapy). For T4N1/2 disease, 63.5% preferred neoadjuvant therapy. Management varied in more complex scenarios: in obstructing cecal cancers with retroperitoneal invasion, 75% favored upfront resection; in non-obstructing transverse colon cancers invading the liver and sigmoid cancers with bladder invasion, decisions were split between upfront surgery and neoadjuvant treatment. For locally recurrent cancers, the majority preferred upfront surgery in non-T4 cases (68.5%), whereas over half (56.5%) opted for neoadjuvant therapy for T4 recurrent disease, particularly when vascular structures were involved.

Conclusion

The survey reveals a paradigm shift among colorectal surgeons in Australia and New Zealand toward incorporating neoadjuvant therapies for managing LACC and locally recurrent colon cancer. While upfront resection remains standard of care, there is increasing adoption of neoadjuvant strategies to downstage tumors and potentially improve oncological outcomes. Further high-quality evidence and randomized controlled trials are warranted to refine patient selection and optimize treatment protocols in these challenging clinical scenarios.