Impact of Professional Seniority on Total Neoadjuvant Treatment Approach for Locally Advanced Rectal Cancer

Objective: Total neoadjuvant therapy (TNT) integrates whole planned systemic chemotherapy within standard neoadjuvant protocols either before or after radiotherapy for locally advanced rectal cancer (LARC). However, the preference for neoadjuvant treatment type may vary among medical oncologists. We aimed to evaluate the impact of professional seniority on the TNT approach for LARC. Material and Methods: We presented a 20-item questionnaire to medical oncologists as a cross-sectional survey. The evaluation was stratified based on position: early-career oncologists (ECOs) and seniors. Results: We included 189 (62.4% ECOs) medical oncologists. Seniors significantly preferred using endorectal ultrasound as a staging tool (p=0.039). 65.6% of the participants preferred long-course chemoradiation. The most common denominators for TNT were external sphincter invasion, threatened circumferential resection margin (CRM), and clinical stage. ECOs and seniors preferred short-course radiotherapy (p=0.009) and long-course chemoradiotherapy (p=0.041), respectively, as the index step of TNT. Furthermore, 57% of the physicians preferred to monitor treatment response for TNT at 8-week periods. Approximately 47.1% of the participants reported pathological complete response (pCR) rates between 25% and 50% with TNT. The physicians who prefer to administer adjuvant treatment after TNT completion make individualized decisions when surgical pathology reveals non-pCR, CRM, and lymph node involvement. Furthermore, 88% of the senior medical oncologists and 76.3% of the ECOs agreed that TNT should be the standardized neoadjuvant treatment approach for LARC. Conclusion: TNT for LARC is well accepted among medical oncologists, and professional seniority seems to affect its clinical application.