Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project
Authors: Podda Mauro , Sylla Patricia , Baiocchi Gianluca , Adamina Michel , Agnoletti Vanni , Agresta Ferdinando , Ansaloni Luca , Arezzo Alberto , Avenia Nicola , Biffl Walter , Biondi Antonio , Bui Simona , Campanile Fabio C. , Carcoforo Paolo , Commisso Claudia , Crucitti Antonio , De’Angelis Nicola , De’Angelis Gian Luigi , De Filippo Massimo , De Simone Belinda , Di Saverio Salomone , Ercolani Giorgio , Fraga Gustavo P. , Gabrielli Francesco , Gaiani Federica , Guerrieri Mario , Guttadauro Angelo , Kluger Yoram , Leppaniemi Ari K. , Loffredo Andrea , Meschi Tiziana , Moore Ernest E. , Ortenzi Monica , Pata Francesco , Parini Dario , Pisanu Adolfo , Poggioli Gilberto , Polistena Andrea , Puzziello Alessandro , Rondelli Fabio , Sartelli Massimo , Smart Neil , Sugrue Michael E. , Tejedor Patricia , Vacante Marco , Coccolini Federico , Davies Justin , Catena Fausto 
Published: July 2021

Abstract
Background and aims
Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts’ consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients.

Methods
The discussion among the steering group of clinical experts and methodologists from the societies’ expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020–January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question.
Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations.

Conclusions
The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.