International expert Delphi consensus on management of early and locally advanced rectal cancer

Purpose: Treatment strategies for early and locally advanced rectal cancer are evolving, particularly with the increasing use of non-operative management and multidisciplinary decision-making. The aim of this study is to establish an expert-based consensus on the preferred treatment strategies for early and locally advanced rectal cancer. Methods: A 12-member steering committee was established to conduct a modified Delphi consensus process on rectal cancer management. The committee performed a systematic literature review (2014–2024) to inform survey development. A 49-question survey, including open-ended and multiple-choice items, was developed and refined. A panel of 44 colorectal surgery experts was selected based on academic contributions, and two Delphi rounds were conducted anonymously. Consensus was defined as ≥ 70% agreement. Based on panel responses, 29 consensus statements were formulated. Results: The panel reached consensus on the importance of multidisciplinary evaluation and surgical expertise in total mesorectal excision. Structured MRI reporting was recommended. Total neoadjuvant therapy was preferred for high-risk tumors. Non-operative management was recommended in cases of clinical complete response, with defined surveillance strategies. The role of biopsy in near-complete responders was also addressed. Conclusions: This international consensus provides structured guidance on the management of rectal cancer, emphasizing multidisciplinary planning, the role of total neoadjuvant therapy in organ preservation, and rigorous surveillance protocols in non-operative management. These recommendations aim to standardize care and support evidence-informed clinical decision-making.