Under any circumstances, perform the best treatment for cancer

The coronavirus disease 2019 pandemic has led to the cancelation of electively scheduled surgeries in many facilities. A systematic review was conducted to identify the literature, between 2005 and 2020, investigating the impact of time to surgery on oncology outcomes. Based on the review, it has been reported that delayed resection of colorectal cancer (CRC) negatively affected the overall survival of patients with moderate evidence.1 Under any circumstances, it is important that malignant diseases be treated, and the timing of surgery plays a crucial role. In this issue of Annals of Gastroenterological Surgery, Ali and Weiser et al2 have reviewed the recent advances and controversies surrounding the management of locally advanced rectal cancer and reported the importance of an individualized treatment plan based on the tumor's characteristics and the patient's quality-of-life. They discussed some clinical questions, including “what is the optimal regimen for neoadjuvant radiotherapy (RT), long-course chemoradiotherapy (LCRT), or short-course hypo-fractioned radiotherapy (SCRT)?,” “could some patients avoid preoperative RT or not?,” and “what is the significance of total neoadjuvant therapy (TNT) with the neoadjuvant use of systemic chemotherapy?” Preoperative SCRT consists of 25 Gy given over 5 days and is followed by surgery within 7 days, whereas LCRT consists of 45-50.4 Gy administered over 5-6 weeks with concurrent sensitizing fluoropyrimidine-based chemotherapy and surgery after 8-12 weeks. While the tumor-killing capacity of SCRT equals that of LCRT, the shorter time to surgery decreases the potential for tumor down-staging and adequate pathological response. As for selective RT, a PROSPECT trial is ongoing. Those with responders to neoadjuvant fluorouracil, leucovorin, and oxaliplatin (FOLFOX) proceed to total mesorectal excision (TME), followed by adjuvant FOLFOX, whereas those with poor responders undergo neoadjuvant chemo-RT, followed by TME and adjuvant chemotherapy. TNT can increase the pathological complete response rate and reduce the risk of systemic recurrence. If we could diagnose no residual tumor precisely, we may preserve the affected organs in selected patients. With the increasing response rate to chemoradiotherapy, more early-stage and down-staged rectal cancers have been treated. Devane and Albert et al3 have highlighted the recent advances and current role of transanal minimally invasive surgery (TAMIS). The transanal approach is useful, and the use of transanal TME (TaTME) has been widespread nowadays. Two-sided approaches, intraperitoneal and transanal procedures by two teams, can shorten the operative time and overcome the technical or oncological problems associated with laparoscopic surgery for rectal cancer. Robotic-assisted laparoscopic surgery will be expected to improve TME procedures with its 3D vision and intuitive manipulation of forceps. Furthermore, the perioperative systemic management of patients has also been developing. Ohya and Endo et al4 have conducted a retrospective, multicenter, observational study to examine the effect of continuing antiplatelet therapy (APT) in the perioperative period on patients undergoing laparoscopic resection for CRC who had received preoperative APT. No significant difference in the surgical outcomes or postoperative complications was observed between patients with the continuation of APT in the perioperative period and those in whom APT was discontinued. Thus, continuing APT in laparoscopic surgery for CRC may be better. From now on, new treatment modalities, such as immune checkpoint inhibitors, will be lined up in multimodal therapies. The effect of radiation or cytocidal agents on the immune environment is drawing attention. Meanwhile, robotic surgery will increasingly prevail. Computer-enhanced technology with mechanical eye (magnified three-dimensional view) and mechanical hands (seven degrees of freedom articulated instrument) may facilitate the surgical approach for technically challenging operations for advanced complicated cases. Even in difficult situations where some restrictions exist, treatment modalities for cancer continue to be developed steadily. Though the world is divided and controlled with physical–social distances, upgraded treatment strategies for cancer treatment should unite the world for suffering patients. Conflicts of Interest: Author declares no conflicts of interest for this article.

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