'Watch & Wait' in Rectal Cancer Doesn't Compromise Outcomes

Pam Harrison

February 11, 2020

Another study adds to the argument for a watch-and-wait (W&W) strategy for patients with low rectal tumors who have a complete clinical response to chemoradiotherapy (CRT). For such patients, immediate surgery can be avoided, argue researchers, owing to the fact that, should regrowth occur, excision can be effectively carried out in almost all patients.

"In the present study, the vast majority of patients (97%) with regrowth after W&W were able to undergo a curative treatment for local regrowth," say researchers led by Marit van der Sande, MD, the Netherlands Cancer Institute, Amsterdam.

"Our data suggest that the initial primary surgery treatment options for rectal cancer are almost always available in patients with local regrowth [and] there seems to be no increased risk of surgical complications after the delayed surgical treatment," they add.

The study was published online February 7 in the Annals of Surgery.

These latest data add to the ongoing debate about W&W for rectal cancer. Treatment typically entails neoadjuvant chemoradiotherapy followed by total mesorectal excision, which often leads to permanent colostomy and/or disturbed bowel function. Proponents of the W&W strategy argue for delaying this surgery in order to preserve quality of life; opponents argue that this may lead to worse survival.

Results With the W&W Strategy

For their study, the team evaluated two cohorts of patients who were assigned to W&W. They identified retrospectively patients with a suspected local regrowth. They found 89 such patients of 385 patients with near-complete or complete clinical response treated according to a W&W strategy. They analyzed the outcomes for this group.

Almost all of the 89 patients (93%) had received neoadjuvant CRT at the time of the primary diagnosis. The remaining 7% underwent short-course radiotherapy with a long interval.

Median follow-up was 28 months. Median time from the end of neoadjuvant radiotherapy to the diagnosis of local regrowth was 9 months.

Nearly all of the patients (94%) underwent surgical excision of the local regrowth. The majority (69%) underwent total mesorectal excision (TME), and 30% of tumors were locally excised.

"The 2-year local recurrence-free rate in the 84 patients undergoing surgical treatment of regrowth was 97.8%," study authors report.

At 2 years, 91.8% of the group were free of distant metastasis. The disease-free survival rate at 2 years was 90.3%. At the same follow-up point, 98.4% of patients were still alive.

For the few patients (5/89) who were not treated for local regrowth, patient frailty or refusal to undergo surgery were among the reasons for not undergoing treatment. None of the regrowths that occurred in the study were considered technically unresectable, the authors comment.

In this study, patients underwent surgical excision after a median interval of 12 months after completing CRT.

"There is a concern that delayed surgery can be more difficult with more complications because of the increased fibrosis," the authors note.

However, they found a very low rate of serious complications. Only a single anastomotic leak occurred.

There has also been concern that tumor regrowth might be the source of distant metastases. This risk has previously been reported to be higher among patients who experience regrowth compared to those who do not.

The authors comment that in their study, the 2-year metastatic disease rate in patients with local regrowth was 8.2%. It is not clear whether this risk was related to how well patients responded to treatment or whether it was related to the omission of immediate TME after CRT.

Uncontrolled pelvic disease was very rare in the study cohort. It occurred mostly in those patients who did not undergo treatment for local regrowth, the researchers note.

To ensure that as few patients as possible develop uncontrolled pelvic recurrence in the context of a W&W strategy, "it is essential to have a tight follow-up program, with close surveillance, especially in the first 2 years," the investigators state.

It is generally agreed that this surveillance program should include at least a digital rectal examination, flexible endoscopy, and MRI, they add.

The authors have disclosed no relevant financial relationships.

Ann Surg. Published online February 7, 2020. Abstract

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